HomeMy WebLinkAboutWAT2026-00061 - WAT Application - 3/20/2026 WAT 2026-00061
415 N.bit'Street
MASON COUNTY Shelton,WA 98584
( t COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair:360-275-4467,Ext.400
Building,Planning,Environmental Health,Community Health Elma:360-482-5269,.Ext.400
Application for Determination of Water Adequacy
Instructions
1 Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit completed application, with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: 14AX Date: t /Z/Z4
Mailing Address: '? Phone: ,2S - 7zz- 9v
f3C/ , 325'
Parcel Number: /Z 2/— p
Type of Water System Reason for Application
,Public/Community Water System (2 or more ,I ..Building permit
connections) O Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water O Other(explain)
❑ Other(explain)
O Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below if applicable no
to this well, check the Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Z,L Wee er 4'
Water Facility Inventory(WFI)Number: /V/O,?c.
(write"none"for two-party).
I am the manager of this .water system.The water system has been approved for _services.
There are presently/connection(s)in use.This will be the connection.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willing to provide water o this (these) connection(s)without exceeding
'the limits of the water system or any Ii 's s et by a local regulation.
Signature of Water System Manager i` Date . '
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 4/4/2018
Individual Water Well
Water well report(attached to application). Depth 224 ft.
Rl Well capacity Test(attached to application) 20 gpm >400 gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests are noted on the water well report. Results from these tests will be accepted. If the water
well report cannot be located by the applicant or if the water well report does not have a capacity test,.
a well capacity test,which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
l Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14 15_116_22
Water use or limitation recorded.................................... N/A_____N/A Yes
Well Drilled ...�!��....�. .................:.....:................. Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
O I have reason to believe that this water source can provide at least 800 gallons per day;and/or
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant.______________________________________
Part 3: Mason County Community Services Evaluation (staff use only)
Satisfactory Determination:
This.determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied_ Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Cl Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
b
Environ. Health: Y Date 4/6/26
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
2221 Ross Way Spectra Laboratories-Tacoma
Tacoma WA /, t
98421 3 S)—S£2 )
(253)272-4850 Spectra#
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
3 �,�.(� A Collected
Month Dal / yea (_ ,, •z�!mil M
Type of Water System(check only one box)
❑Group A ❑Group Be{
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name or Address:
Contact Person:
Phone: ..oi t
Email: , Cfitrt.--
Send results W:Prbd fatl name.address,by code and*man
SAMPLE INFORMATION
Specific location where sample collected: Special instructions or comments:
cJ
;Type of Sample(chedi Only one-box)
1u tine Distribution Sample(AlP) 2.❑Repeat Sample(Alt')
Chlorinated:Yes ❑ No IQ. tam distribution system after unset,toubne)
/ Unsatisfactory routine lab number,
Chlorine Residual:Total_Free
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date:
Chlorinated:Yes,___.__..No
❑Tr ge (N')
Chlorine Residual:Total._ _Free_ ....
❑Assessment(NP)
4.Surface or GWI Raw Source Water Sample(Enumeration)
S
❑ E.coif O Fecal t-imorod Yes_tdo
5., Sample Colected for Information 0nly:
LAS USE ONLY 1 DRINKING WAITER RESULTS' LAB USE ONLY
❑Unsatisfactory Total Cotiform Present and Satisfactory
❑E.co/ipresent 0 E.colabsent
Bacterial Density Results:Total Conform mpnl100m1.EcoCi mpnll00ml.
Fecal Coliform cfull00ml.
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume O Damaged Container O
Date/Tlme R Lab Reference Number
Recelp emp Cl; Method
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