HomeMy WebLinkAboutWAT2026-00120 - WAT Application - 6/26/2026 4' T 2026-00120
MASON COUNTY 4on,W `"Strtet
Slrettc� 9 R5�1
Shelton:360-427-96/0,Ext.400
Public Health & Human Services Betfair:36O2754461.Ext.40()
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
Name of Applicant: Date: _ `SJ7 L ,2I
Mailing Address: èi1 ^ t'none: `ac _
Parcel Number { .\ l - 1
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more j Building permit
connections) O Division of land:
Individual water source (one connection), #of Parcels? SPt.
Well ❑ Boundary line adjustment
O Spring/surface water ❑ 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)
❑ 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,
❑ 1 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.9oy
J,Fii Forms\Drinking 13 Pater Revised-O-5lOi2014 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 ft.
Well capacity Test (attached to application) 1 6 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)
O Method of disinfection
O 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)
Ix 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,Tile 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).
� o5U"L u Reviewer's Signatures:
Environ. Health: Date 6/26/26
This form may be scanned and available for public view at www.masoncountvwa.aov
F'j�c 2 of
WATER WELL REPORT AyVitcrUon No . . ....
Third Copy-DrftIor•a Cops STATE OF WAtiMGTON P'armit No ....
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g. (x) LOCATION OP WELL -.____. o n aa. _Ta-U-N.,sue_bsf.
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rt DWO of sm"Mad'wait (19- VaVl0
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O (7) PUMP: maaut et�a�aes toV — ,
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dl xtata sail .,.lm ft erawaawn.attar bra. WELL DR1Li 's STATB'SSENTI
E tru the a of i
wrjUed r my.ni riadiction and this report i
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b ttiuwr tsbsa a.n wai pomp turaad am (wabe Ioai
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Printed from Mason t.;u :fly UMS
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
V 'aRAaD 360-967-7010
GN021/F04 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Tme Semple County
6 1 � l Collected El G- t^
vam oq Yes -L: 00 /Yl
Type of Water System(check only one box)
O Group A E3 Group B JS DOter P1///
Group A and Group B Systems--Provide from Water Faciles Inventory(WFI):
ID/
SyalernName (JOGA€ e r Lv /Y&S
Contact Person; -i / 1 NQ cAe?
Day Phone:( ) Cell Phone:( )
Email: Eve.Phone:( )
Send results 1x(PMI k name,address and zip code or efnal9
//6 ,'4// A'/e.
.r e,t /,5 14/14 19,5 3 o`Z
SAMPLE INFORMATION
Sample colecled by(name) /fl�
..J r�J
Soeckñc location where sample collected: 1 Special tnstn ctions or comments:
.(d/%oc2 l✓A
Type of 8ampfe(select only one type of eempte from types 1 through 5 below)
1.❑Routine Distribution Sample(A/P) 2.❑ Repeat Sample(A!P)
Chlorinated:Yes No _ MmdistrbAonsysamallaruleai retiree)
Unsetlsfaclory routine lab number
Chlorine Residual Total_Free_
3.Ground Water Rule Source Sample
Unsadsiactory routine colect data:
SJ
Chlorinated:Yes No_
❑Triggered(AIP) Chlorine Residua):Total_Free_
DAsseasmenl (A/P)
4. Surface orGWl Raw Source Water Sample(Enumeration) I I l
❑E Cog ❑Fecal Rend Yrr_He_ S
6.t&i Sancta Coaeded far knfomletlon Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsallsfactory Total Coilorm Present and ®Satisfactory
❑E.cotpresent ❑E.co6absent
BacterlelDensity Results:TotalCotiform /l00ml. F. /100mi.
Fecal Cofform /100mL HPC /1 ml
Replacement Sample Required: ❑TNTC 0 Sample teo old
❑ Sample Volume ❑DamegedContabwr ❑
Da WTyM R lab Reference Hunber
Z� r0a
Receipk Temp C': °de S M 92 23 B
Dale Reported E DO H Lab Use Or y:
DOH Lth Sam{leM
285-
DDNF—OJr71/(efta" )•eew ey FIMl1n'Ynlllu(aM el IrD07TY od 711j
7N1 W CFaI {T..fAlbll Y A'ldoAR lF�Y�T111Y
Vanguard Laboratory '
2635 P.arkmont Lane SW,Suite A
Olympia WA 98502
360-967-7010 VvJ;D
LAPaUTaXr
Nitrate/Nitrite
Analysis Report
Date Collected: (MM/DD/YY) // / System Group Type:(Circle one.) A B Other: ("J
Water 5 stern ID Number. __ S stem Name:
Lab Number/Sample Number. 8 ,JO135_ County: a_ o
Sample Location D" vZ- Source Number(s) (List all sources if blended or compositedl
" VAe,*a'1, (.✓4 5& /
Sample Purpose(check appropriate box) Date Received: (MM/DOTTY) Q J O ZI!t.
❑ RC—Routine/Compliance(Sat&ttesmonitoring requirements.) Date Analyzed: (MM/DOTTY) 0 0 2
Date Reported: (MM/DD/YY) 0 �0 2 .&
Li {Confirmation of chemical result)'
1—Investigative(Does nor satisfy monitoring requirements.) COMMENTS:
❑ O—Oth er(Specify—does not satisfymonitoringre uirements. V O D
Sample Composition(Check appropriate box.) Sample Type(Check one.) 3Pre-treatment/Untreated (Raw)
ED S—Single Source ❑Post-treatment(Finished)
❑ B—Blended(List source numbers in'Source Numbers'field) ❑Unknown or Other
❑ C--Composite(List source numbers in Source Numbers'field.) Sample Collected by:(name) 5'°S&.
❑ D—Distribution Sample Phone Number: —
Send Report to: Bill to:(Client name,)
f$ n5 tau lz�4,X o//'r f/I
Analytical Results
Data I Exceeds MCL 2 Method/
DOH# Contaminant Qualifier Results MRL SDRL Trigger MCL Units (X if Yes) Initials
0020 Nitrate-N ND 0,5 0.5 jj0 10.0 mg/I. Hach 10206
NOTES
*Confirmation:include the original lab number,sample number,and collection date of original sample in either comment section.
--No trigger value for combined nitrate plus nitrite.
Data Qualifier:A symbol or letter to denote additional Information about the result
DOH#:Department assigned contaminant number.
Exceeds MCL(Maximum Contaminant Level):Marked if the contaminant amount exceeds the MCL under chapters 246-290 and 246-
291 WAC, If you have questions about this result please contact the department's drinking water regional office in your area.
METHOD/INITIALS:Analytical method used/Initials of the analyst that performed the analysis.
mg/L:milligrams per liter or parts per million.
MRL(Method Reporting Limit):The lowest quantifiable concentration of a contaminant,
SDRL(State Detection Reporting Limit):The minimum reportable detection of a contaminant as established by the department.
Trigger:The department's drinking water response level,Systems with contaminants detected at concentrations at or above this level
may be required to take additional samples or monitor more frequently.
LAB COMMENTS
Revised December 2021