HomeMy WebLinkAboutWAT2026-00106 - WAT Application - 6/29/2026 WAT aka&- d
( j MASON COUNTY 415�.6 s Street
Shelton,WA 98584
Public Health & Human Services Shelton:360-427-9670,Ext.400
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 on Applicant: J e tii9 h?-c c,.r Date: 1
Mailing Address: fG'A// //�,ozp r� ;s n� Phone: 5O 5' , 6,�2 -Lj'36 J
Parcel Number: 2,2231/ 766203 2p
Type of Water System Reason for Application
'Public/Community Water System (2 or more m"uilding permit e?W —OV t6(P
connections) ❑ Division of land:
'individual water source(one connection), #of Parcels? SPL
'�Iell ❑ 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.
Two party well
Part 2: Water Connection Information
See WEL2025-00095
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)
❑ 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:1EH Forms\Drinking Water Revised 05/08/2024 Pape 1 of 2
Group B Water Systems
II'Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
Xi Water well report(attached to application). Depth 163 ft
N Well capacity Test(attached to application) 15 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.
IV Satisfactory bacteriological test within last year(attach to application).
Individual Spring/Surface Water
❑ 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-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).
> � Sw� Reviewer's Signatures:
6/29/26
Environ. Health: Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 oft
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,• nteed From
Ptinted from Masson County DM
Arcadia Drilling Inc.
P.O.Box 1790
Shelton,WA. 98584
Customer: Joshua Munderloh Well Tag#: BBB328
Site Address: 90 NE Pine Camp Rd, Beifair Depth: 163'
Date of Test:3131125 Static: 132.9'
Pump Set: Unknown
TIME •--GPM LEVEL RECOVERY
1 Mm ... M... TIME LEVEL
n 15 15 1 133.6
2 Min 15 133.6 1 Min 132.9
3 Min 15 133.6
4 Min 15 133.6
5 Min 15 133.6
6 Min _15... 133.6
7 Min 15 133.6
8 Min 15 133.6
9 Min 15 133.6
10 Min 15 133.6
15 Min 15 133.6
20 Min 15 133.6
25 Min 15 133.6
30 Min 15 1336
35 Min 16 133.6
mow'; 40 Min 15 133.6
45Min 15 133.6
50 Mira 15 133.6
55 Min 15 133.6
1 Hr 15 133.6
Total Gallons Pumped: 900
Printed From < , [MVIS
Printed from Mason County DIVA
Thurston County Environmental Health
412 Lilly Rd NE t Olympia,WA 98506
360 867-2631
THURS ON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
/ Collected
iryiIAM
'a 0 PM
Month Day Year 6.
Type of Water System(check only one box) Private Household
❑Group A ❑Group B 'Other 2.
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person:
Day Phone:( ) Cell Phone:`'
E-mails
Eve.Phone: )
Send results o:(Print full name, &ess and zip code or email address)
SAMPLE INFORMATION
Sampje collected by(name):
/
Specific iocatioic or address where 'Cs ple collected:, Special instructions or comments:
- - '
Type of Sample(must check only one box 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)
❑Fecal—Surface,GWI,springs inumeration) Unsatisfactory routine lab number:
Filtered:Yes—_No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
Other
S
4. Sample Collected for Information Only
Investigative Construction I Repairs._"B._ Other _
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent
Coliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform _ /100ml. E.coli_.... /100ml.
Fecal Coliform /100ml Enterococci _1100 ml.
Method Code: .SM 9223B ❑SM 9222D Date and Time Received:
❑SM 9215B ❑Enterolert®
Date and Time Analyzed: C. L'1.L Date Repoded
Sample Number(DOH number plus five digits) Lab Use Only:
8 0 -375
DOH form#331-319(revised 11123) C —1 G�