HomeMy WebLinkAboutWAT2026-00097 - WAT Application - 5/12/2026 VAT 2026-0.0097
415 1.60"Street
Shelton,WA%584
Shelton:360-427-9670,.Ex t.400°
Public Health & Human Services Selfair:360-275..4467,Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part I 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
� 1
Name of Applicant: v, d 6th Date: '
Mailing Address: Z9 . IWA ? 5tY Phone:
Parcel Number: 3 O /Y 3 - -
Type of Water System Reason for Application
Public/Community Water System(2 or more l Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ Other(explain),
0 Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below if applicable—no
ta this well, check the PubliclCommunity Water signature required)
System box.
COM2026-00034 and 35
Part 2: Water Connection information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: r'"4e-- ' 4e- - . l
Water Facility inventory(WFI) Number: O 7 7It 3 (write none"for two-party).
O 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.
t . 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 in icate,on the following,line the nature 0f
this change: e4 L — k rv4c. ••^•`
This water'system is able and willing to provide water to this (these)connection(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager r Phone
Signature of Water System Manager '3C Date
This form may be scanned and available for public view at www.masoncountvwo.gov
.WX-flHi Forms%Drinking Water Revised 05/0 /2024 Page'1 oft
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
o Water well report(attached to.application). Depth ft,
❑ Well capacity Test(attached to application) gpm 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.
❑ Satisfactory bacteriological test within last year_(attach to application).
Individual Spring/Surface Water
o WDOE permit(attach to application)
❑ Method of disinfection
❑ 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-Deterrnination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements°may apply. Chapter
36.708 RCW.
Unsatisfactory Determination;
Applicant's water suppiy,does not appear adequate to meetthe needs of its intended:use.for the following
reaSon(s).
� l eviewer's Signatures: 5/12/26
Environ. Health: Date
This form may be scanned and available for public view at wwW.masoncountywa.alov
Page 2 of
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• 412 Lilly:Rd NE Olympia,WA 98506
360 867-2631
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-mail; ≥:ve Phone ( )
Send re 1#s to(Ptn Ate rune address end*ode ems 9r s}
SAMPLE INFORMATION
Sample collected by;(name}
Spectftc tocatlen or'address where sample oo11eoied Spots tnstruatfonsxar tt nts:;
Type of`t3arnpte(must check onty one tax of 1 tiiruugh 4 listed below)
is atuf;ne Distribution Sampfe ° '� ReReat Sarppte:(affer urr�at<rou₹fns}-
Ch nnated.Yes__No „_ O Dtstctbuon:System..
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3a Ida nrWater SourceSample Chia ne Residual Total Free.
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4:Q Sample Collected far InfbirnetIon Only
titl st ebve- CORSruebt}i1 P pans Ofttar
LAB USE ONLY. DRINKING WATER RESULTS US E ONLY
3 £Unsatisfactory Totes Collfoni»Pint and }ttstactocy
O Scot/present p Scot/absent`,
o Olaform detscted"
Re fademaai am eR ,slued:
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o ..
Bactena}Denslfy Results.Total ColtIorm.� = lOOml Ecof1 #904mt:
Focal;Coform .. I100m( EntercccaL "" . .J?O0jui
} MethI`Code X2236 QSMP2f2D tate sod T eda
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