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HomeMy WebLinkAboutWAT2026-00103 - WAT Application - 6/4/2026 WAT 2026-OOJ 03 MASON CO U N COUNTY 415 N.6th Street Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Public-Health & Human Services Belfair:360-275-4467,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 of Applicant: Jason Campbell Date: 5/1/26 Mailing Address: 406 108th St S, Tacoma WA 98444 Phone: 564-546-0742 Parcel Number: 321271400010 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more B] Building permit connections) 0 Division of land: I Individual water source (one connection), #of Parcels? SPL lX Well O Boundary line adjustment O 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: Water Facility Inventory (WFI) Number: (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. O 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 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 Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well ® Water well report(attached to application). Depth 154 ft. l Well capacity Test(attached to application) 25 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 within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 1 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) gi 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. ❑ 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: 6/4/2026 Environ. Health: rJr Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATEWELLEPORTi s Notice or lttt at a. ECJLOGY tit ashz� t�ts ,. L r SIto WCI (Irmo than n tTg. xitttttaamthfot �c3tPfca� +i , £tom. 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A: 1 � � r t _ . arrzrdfi p1xs cC+t7s i4'ufesuua u t t �rrr ur r€gr€sr Ado PeMw k a t fe' f�fa$tt 'exam till Plintd. ftom Meson County D 8 -83634l. • l a Thurston County Environmental Health 412 Lilly Rd NE t Olympia,WA 98506 360 867-2631 THURS TON COUNTY' COLIFORM BACTERIA ANALYSIS Date Sample Collected• Time Sample County f I Collected ❑AM #44 Month Day Year —— PM Type of Water System(check only one box) Private Household ❑Group A ❑Group B O Other Group A and Group B Systems—Provide from.Water Facilities Inventory(WFI): 1D# F System Name: Contact Person '1( ,O Day'Phone:( I;I — 25.5 Cell Phone:(Sa..vhz 'tS T ,c V`e S f'1 0 Eve.Phone: 1Ss-ti E-mailtl�'l� ( Send results to:(Primfull name,address and zip code or email address SAMPLE INF0RMAtI0N Sample collected by(name)s , , V2.o Vl Specific location or address whew sample collected: S�f itlsuctt �'` ments 110 O r - �fSr Type of Sample(must oh ck only one of 1 through#4 listed below) 1.❑`,Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No ❑`Distribution System Chlorine Residual:Total_Free_ Chlorinated:Yes No 3,Raw Water Source Sample Chlorine Residual:Total_Free_ ❑'E.coil—GWR(AIP) o Fecal—Surface,GWl,springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No - 0 Assessment Monitoring(A/P) Unsatisfactory routine collect date: ©Other I I S 4.[I Sample Collected f r Information Only Investigative. t Construction/Repairs . Other LAB USE ONLY INKING WATE R RES,I,1L S LAB USE ONLY Unsatisfactory Total Coliform Present and vSatisfactory ❑.E.co!i present O E.coii absent No liform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform. 100m!. E.coli I100ml. Fecal Coliform /100m1 Enterococci /100 ml. F Method Code.- SM 9.223B ❑SM 9222D Date and Time Received:O°'72 ❑SM 9215B ❑-Enteroleri®. 2.-25. Date.and Time Analyzed: 2•,+ 5_1 Date Reported= - P1,y Sample.Number(DOH number plus five digits) Lab Use Only: ( 0 8 0 DOH Form#331-319(revised 11123)