HomeMy WebLinkAboutWAT2026-00133 - WAT Application - 7/22/2026 WAT 2026-0D 133
MASON h, 415 N.6a'Street
NTYShelton,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.a 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
An approved building site plan`must accompany' this application.
Part 1: Applicant/ Parcel Identification 7/22/2026
Name of Applicant: Erik Lund Date:
Mailing Address: 113 Anion Ave Bremerton, WA 98311$lone: 7187556513
Parcel Number: 220247590044
Type of Water System Reason for Application
g1 Public/Community Water System (2 or more 1 Building permit BLD2026-00593
connections) O Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well O 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.
See WEL2024-00025 Two party
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
r
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
ll Water well report(attached to application). Depth 381 ft•
6r7 Well capacity Test(attached to application) 23 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)
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 r6 68.040'-Determination of
Adequacy for Building Permits are satisfied Additional Growth:Management requirements may apply Chapter
3670A RC.W
O Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
•reason(s).
Reviewers Signatures:
• tJ1%t _. :7/22/2,026...
Environ.'Health: Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
WATER WELL REPORT .R oEPM TENT or ofu, ,tt t s za7
ECOLOY- u,tit t oto ywolf mT t st
Ty a of Woitk Sate of Wasltirigtan
Site We 1 l�Iame(i! c thaussna Well;* .
• O L is to ct PtOt,t • WaterR gtu Pk No____________________
Ite No.
glace CDom U Ittd Ltjal OAlunictpA,, pt tcrtyf)WnerName JAAttES PYL,E
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• osstspctioaTlpet ht# -
4`S sw vrdt- CI . att .t3 ktitd d+Cable Toot tY tEf TQt$ + tttt r M
Ct tj MOYTttx Fatticl Pro. 22024759QM& =475
f#ascmlos Vamcler of"tmi'rt�g Q rn,,m'381 ft Wks a vrrimticeupMot+ed for this a ill fl Yes 1 No
IFpthotdwcfl381: ;II,
WflIfyvs,,v&at waive theo -
CLg rd
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t Cg -'6 'I 378 CS O lea#doss(see imi is is on ga c 2) I++WV Mort(,3Y1
0 I 't3 iri, ilL O i 'O �. ! NW`1'4-tl,of tttaa NE r.;Section 24 To reship " :•ice 2
Vii. i date. __. I b I 4Y 2"f 101$
O i
ire C3 I Ll E$ t atitude,( mm 4712345)412h1018
0 "
• LonBettsde(Eatngie;-220.1245) 122 87�i tb•w�
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• r ee,mt ;alitlayr' vitbse €
`Yes O`Na K-later info a t3oa Use' 5 tt
as '# Matc*a1 -Prom To
CLAY&GRAVELSAN} BROWN 0 iso
me
1[[? u»titi.8 im 9 t 12, of 374 Il:to'3381 R
& _ L FEAT Btt()VYN 18i)-. i90.
t;LAY°&"SAND 81,11E • 190 2213
SstttUP r pica C3 Yes- ;7 Nm " orpx*,ouwtal nt.ht 229 245 etcralsPkcWBeams w •
GiftY&GRl1V�18t.UE
CLAY SAND&GRAVEL BROWN - _ 245x" 2755
• StuCasx " I v- esDo "Tt " SAY SANi BLttE275, 365
astd i}ss 1 8�i GRAVEL 1420 GREEN 365 381
rs l myslr4 ir�atiwtn leer atet? 13 Yap @ to
Type a wsai Dopth Orsu ttc
Atimp.t,4 tut ttsiLr's Naar UMS 'SI 3'• H[';3 PtimpiA$alcc depthC ft. DcsWxd flow tast:-18
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Smhc lcs t f2a•f.trekWti ofw#c 1ng. Date 4.2224-
- Aitcslangzsva_._,�&a.-�ersgtatciach - -_ .Mesovxx risct if, ' (cp.va1vc.cc)
kapua3esC 'LINO- Yes "by4
Yid 23 `pgm 2 .. tt dradowc alter 4 free
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'ft mkt ice+vstah"a ,,_tC dacve ewn fl -_
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trproaraactiatl? -
Tune 5(tcr Lavel Yarn Water t.evel Tine Water l.cs^et
t otpt tesf
SuicrttsrxtiWeith, „_tG drdwdowaafrr___ hrs
Alt sat _ gpmwidt sacsn se#at.�It fur her tta
Axe acv
ttiro ctfwa er P Was i' ressulysi`ttmda7 O Yes".i9:No` Stu'r 44 It jr 4.48.24
WELL,CONS RUCTTO? CEI C`W ATION 2 eonstcuctai*n4(or arce�st r lbaigty frusIructän ofztnr+IHe4E,mpd i txirr 3iaz r Britt stl, lasbiis tt welt
caisstfnt ivn srds.Matexi1suse4aodthe inft tion tp rtcd the-vs are Mc to Iny t3xiowkde and bdit£
i sitt4x C lliaiuee C 3sE—t?rint; 't CLAYTON PIUS pZ'itti t Ctt�tsnitttr G LVAfATER'ORWUN NC.
__• • Adts 10921 NW HOLLYRD
I is sc&ado 2516 city,State,Zip'BR EMERTO1i;WA 98312
"SP s ucc s c Nb. C .s
Spoz�ot's St aux`:. it istzRtiva Zd C 0OLWt}941QitA 7ate;S-i 2.4
•`. P •050 "sv lilts) °t"t n ed tFtls rz rx c 1 uIsle r rutt the FY rsef t ur Pin ium ut
�" t ;n iPo116ttt $4AtffiNt
I�Pntd from Mason County DMA
Thurston County Environmental Health j
412 Lilly Rd NE Olympia,.WA
36O867x2631
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Ti `
COLIFORM BACTERIA ANALYSIS
Date Sample collected Time Sample County
Collected
ate✓
Moot'h Day-
Type of Water System(check°ontp one bmt) ❑ Private Household
Group A ;.D,Group B Ottieri{at`t +
GraupA and Group BSystems-Provide;from Water Facilities Inventory FI):
:ID#-
' System,Name
Gontact'Person ;'
Day Phone•( Cell Phone:( . )
E-mail:.
'EvePhone:( . )
Send results to(Print full name,address and zip code or email address)
,. , .
SAMPLE INFORMATION'
Sample collected by(name)
Mfg
Specltic location" raddlesswhere,sam le coiiected Special instructions orcomments
max f4 �
Type o Sample'tmust check only one box of#1 through fisted below)
1 autine Distnbation Same 2.Repeat Sample(after-unsat.routine)
Chlorinated Yes No - �1 Dlstnhutian System-.
E a
1 K ChlorinsResldual Total .Free Chionaated:.Yes NQ_ .
3.;Raw-Water Source Sample Chlorine°Residual:Total;_Free_
Di coil—GWR(A!l /:
❑Fecal sude s owl spiirgn(numeration) ,Unsatisfactony�routtne lab number`:
g' Fltarsd Yes No= _
Q'Assessment Monitoring(NP) Unsatisfactory,routine collect date,,
..❑Other fb
S
A.Q Sample Collected for information Only,
Investigative Consfuctlon/Repairs Other
LAB USE ONLY PRINKING WATER RESULTS LAB USEANLY.,,
❑Unsatisfactory Total Callform Present and ; Satisfactory
fl E qo,,present ❑E.coii sent
�xoGoiiform'detected.-`
Replacement Sample Required:'
❑'Sample too old(>30 hours) ,D TNTC ::? ❑—
Bacterial Density Results:Total Colifonn /100m1 E-coli . 1100MI:
Fecal Coliform /900mt Enteiacocci 1100 ml:
Method.Code SM 92238, `[]SM 9222D Date and lime Received:,
D SM 92156 ❑Enterolertw ?°
Date and T,Ime Analyzed: ' fN :DateReporledçl
Sample Number(DOH number-plus fvu digits) Lab Use Only:
. a.. , : {
DDH Form#331319{revised itlZ3l