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HomeMy WebLinkAboutWAT2026-00136 - WAT Application - 7/28/2026 WAT 2026-0Q136 MASON COUNTY e' s�reer Sheltm�.WA H8584 Shelton'360.427-96;0.Exu 400 Public Health & Human Services selfniv 360-175-446,7,Em 400 Application for Determination of Water Adequacy Instructions t. 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 \ Date. 2—q 1 2.tp Mailing Address: Gtyttvj1& 9A4 {Phone: 7pD- —'q ( , f 3 Parcel Number: Type of Water System / Reason for Application ❑ Public/Community Water System (2 or more )71\Building permit connections) 0 Division of land: Individual ater source (one connection), #of Parcels? SPL Well ❑ Boundary line adjustment ❑ Spring/surface water 0 Other(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. 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. ❑ 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_F El Fmm I>dnldoe O:uiv Revised 05;1)8/2024 Vine I oR Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well p Water well report(attached to application). Depth________________ft ® Well capacity Test(attached to application) 20 grind >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 lest, a well capacity test, which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. El 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) 6 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 8.68.040-Determinallon of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply.Chapter '.. 36.70A RCVS ❑ Unsatisfactory Determination: Applroent's water supply does not appear adequate to meet the needs of Its intended use for the following reason(s). , Reviewer's Signatures: 7/28/2026 Environ. Health: Date This form may be scanned and available for public view at www masoncountvwa.aov Page 2 oft RECEIVE® WATER WELL REPORT FES D 1 &I .R -E.wr.xrowe*.a. ; mn that CURRENT v14tt oww No udMaHt No.WE07R77 WBb to xContmcjD.Cw NmkCI(Yin circle) `tf„(,' Unique Ecology Well ID Tag No. RAHBII eat of Ecology X Cecomn1 ion aO�� �� pxommiaion ORIGINAL INSTALLATION WM,,RiSM ftoo,No.EXEMPT WELL = Notice of Intent Number PmpeelJ(Mxr Nome SCOTTMACALEVY 0 . oo tIc !J IMuund ]MwcµS C 1PY „yd. Ta wex ❑mM. Well 5imet Address STATE ROUTE 101 MASON tTfl0laW owxWaxWme ywwNlxarMna,wl flews ❑ �� Ciry SHELTON County tp Nn,a loulionNE_114-114NE 114 Sect?Twf11N R 4W VSN C Check MN tl. �, s.wa+wwa DicS c"vl p za.. �.e,alse Still REQUIRED) Rr wWMp°ne fat Min5ec cnNvw- Wt onANs LaVLong I Dey t'yw N Wt b awe noe,- a w 1P9—_ n Long _� Long Min/See an=1F0 aw__ 10 Is^aa' n� _ uw.v,aa _n Tex Parcel No.(Required) Rn^ rroexoeo-de� r..W,u, o.tra4xW W a.r..a�a «`ai o wndas..nr w WEETSI s 2e o1' enyM mna e. fM'EsIce 9.m Lt' ' ItnE AoomdiAL 5HP£r51E NPC635Aar) y. �Nx R�v. Im'w^ MATERIAL FROM TO at.wBROWNSILV VWITH GRAVEL AND 0 IE T� uoA.l w. P a COBBLES tI alga _ -- -- n BROWNSICIYSANDANDGRAVEL 21 St G BROWN SILT BQ/NUSA..GRAVEL. 52 d hyk 4se.d W! [] V. ©w Sia am.d M TIGHT.COMPACT 51 ,b MewaN lRaai aro a' BROWN SAND ANDGKAVEL WET 83 SI*tnS a'Y. ❑ Nx EcowE^' s-,— a LARGE GRAVEL, E SAND,WATER IN Na.,w.n.wwl BENIDNITECHIPS Iq aa.r R.,wa.x,awueH.esr Cym © w Try1 K.aa. a,Vln uEmWa Mrmof Su.u—off HIV:x..R.tWaYiMRw O .ATwtms:uMExl.ew.elmwo..�ww _ a Z 1 sue N,nl Sv n e,w. wNwdl o-.. I1R7A7 --_ i � .avnidlN% (W..dm ncJ 'O TRSia,wHM.w'Rw.,MwaeRwWlxweaeabw nwcN.l y w.,P PN. eee C r. C Nx o Qf YW'. Wlu,i. ., aA�+A.n 0ht xn .O2 Ys __ lathwe. iW --n trn0mm ene__xn ?, � YYW. IPI�®vrx ��adwdaw�Pv �M Pacoi+�fa—i.M„�u.n.u�awxn Vwrown,MMllwNr kM nwmwUlmm+N _ __-_� dw Mleee P bv4we a.. PN Bait,T.e ylAnie wxx .: IB Amu 220 WIn.wax weewwgq___fl (a ,s.Q A,m:.a no.__se.°•. o+ s- Date 11RIA] Completed Date I2)277a w{Oeu,aMMe Watts tl.w a^� ❑ 1. WMLCDNSTSUCIIONt cw 4cAra IeonitrvetS and/o 4ectR,alpoeaNRRD l.romlrvetiM of IbsY,eLand Rs cpmpllance wMi 111 WUN,9tan WNl c.mnraior,5.eiafth Mawaids luca 1 in mlatim rePoned above ert tnx to my Eer ,,,C F aM RC cicl QDrRRr0Pw8' 0T.NNe Nanraf JOSHUA PP P,11R9CmryxaY ARCADIA DRILLING INC. Aamcss PO BOX 1790 O le2nEm/r.rs SiEralwe WA 98514 shiner or nilec LmMC No. 11741 CaY.S...ltp SHELTON --- 6TMINFE IXakl'r La No. DRANDON HICKS Cplllxcm , PuIUY Sanx Re1iwMion No ARCADDI09SKI twc 11!2&7 kmlgyn.E SI1ppe1 PN D,Mol., ECY H61d01Rw Wtl Thurston County Environmental Health _ 412 Lilly Rd NE •Oivmpia,WA 98506 360 867-2631 THURSTOn COUNTY _ COLIFORM BACTERIA ANALYSIS Dale Sample Collected Time Sample County 4 Colkcletl �a,a a�n nor `�-3 UU11{ so7't Type of waler System(check only one boy) Private Household ❑GroupA ❑Gmup8 ❑Other Group A and Group B Systems-Provide from Weer Fadlites Inventory(WE): ID# __ System Name' Cooled Person CL Day phme: Cep Phone E-mall: Eve.Phone_( ) Send results to(punt full name,address and 2'p cods eena9 address) 5c5tFQIewoodColl, t ran- SAMPLE INFORMATION SemPb kc�by nagoj C q L Spedfic toiron or less where sampb collected Speul'mstruoons or comments: Type of Sample(nest chedr only one box of#1 through#a 1Nkd babes) 1.❑Routine Distribution Sample 2.Repeat Sample(alter uneat.routine( Chbdnaled Yes No_ ❑Dlstibution System Chorine Resdual:Total_Fret_ Chblinaled.Yes No 3.Raw Water Source Sample Chbnne Residual Total Free ❑E.colt-GWR(NP) ❑Fewl-Sur s.....swg{rJen Unsatisfactory routine lab number lillend.Ye, No ❑Assessment Monitoring(AR) Unsatisfactory routine coned date. ❑Omar I S A Sample Collected forlMormation Only Imrestyative_ Consbudbnl Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total CdRorm Present arid Satisfactory 0 E cdi present 0 E ooh absent PiSCoitmi detecled Replacement Sample Required: ❑Sample too old >30 hem ) ❑TNTC ❑ Bacterial Density Results.Total Cditoml IlODmI. E.wli —ll0Dml. Feral Culitorm._ _ 1100nil Enteromcci__ J100 ml. Mehodcode<SM9223B ❑SM9222D Dale arc me Rxevef K'1l ❑SM9215B ❑Enterolerl® 4 I T) (. C ¶ z beta am nuts Analwed: -I I T≥ DolenepMod:: ') & samge Nwroer lLPl rvmterWs me di0il tab use klr o a o