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Home My WebLink AboutWAT2026-00117-WATER ADEQUACY - WAT Application - 6/22/2026 WAT 2026-00117 MASON COUNTY 415 N.6a'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: Suzanne Rudoll Date: 6/22/2026 Mailing Address: 323 E Lantern Loop Rd SHELTON,WA 98584Phone: 360-490-8980 Parcel Number: 420194100000 Type of Water System Reason for Application l Public/Community Water System (2 or more lid Building permit BLD2026-00522 connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water El (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 to this well, check the Public/Community Water signature required) System box. See WEL2026-0001 0 Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: Ardie/Rudell (Two Party) Water Facility Inventory(WFI) Number: none (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 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 l Water well report(attached to application). Depth 55 ft. >400 Il Well capacity Test(attached to application) 11 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 ❑ 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) ja 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. •`•i] . 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: 6/22/2026 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 • aayye� asr1�� s rr Water Well Report II or Afl Md [i F 'our well mustbe properly tagged prior to 9ubmUth this fam flPAx��tlro� �A+o` k+��`,�tt�i+opts r�u]�6r�t�Ild�, � ��r� ��t�': .• ' . 1NA t n�qf F to i�PiJ.f3wt 7' +mt,' ► t 86t , t.. ..:x. x *ate ¶neyWefgffiinher .' .: tJ(rtipntpI r ønen*tons :.Pettyyat1 91m&etofeU P,,,,In. , Depth ofoptet It_5 it (11`known) lyylte: P 3 i 4*eta it Peratat1acO$ It tees lu 'tla+� 1l ► n ! �� •'� � r� � �� rt��ur �tic .1fPeSt" tst��rfi � 1Puc ; Dother.;�,,: .. DlaeleteL fromJt(o; .,L TonspzqN, Ran 1i4, QEWMoiWWM $ ipn milt• _.. � ! 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Il I I ii 1 - I t I 11,1 ' 1 / 4 ' I - f MOERKE&SONS PUMP&DRILLING,INC 1162 NW State Avenue, Chehalls, WA 96532 (360)748-3805 PUMP TEST STEVE ARDIRE 3/16/2026 WELL SITE ADDRESS:1621 W LITTLE EGYPT RD,SHELTON WA 98684 Pump Make&Model:112 HP Pump Set At: Sounder Make&Model: Make&Model:MASTER Measured In:GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES_ 0 0 156455 5.3" 000 GAL TOTAL TEST BEGAN 1. 11 156466 9.7" 2 11 156477 10.6" 3 11 156488 10.8" 4 11 158499 10.9" 5 11 156510 10.9" 6 11 156521 10.9" 7 11 156532 10.9" E 8 11 156643 10.8 9 9 11 156554 10.9" 10 11 156665 10.9" E 15 11 156620 10.9" 20 11 156675 10.9" 25 11 156730 10.9" 30 11 166785 10.9" 35 11 156840 10.8" 40 11 156895 10.8" 45 11 156950 10.8" 50 11 157005 10.8" . 55 11 157060 10.8" O 60 11 ' 157115 10.8" 66 11 157170 10.8" 70 11 167225 10.8" 75 11 157280 10.8" 600 GAL ENO RECOVERED IN 2MIN IUSEO SIGNATURE DS S PU AND DRILL NG E t 0. 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