HomeMy WebLinkAboutWAT2026-00198 - WAT Application - 9/24/2026 WAT 2 , - a d [c
MASON COUNTY Shelton,
8584
Shelton,WA 98584
Shelton:
Public Health & Human Services360-427-9670,Ext.400
Belfair:360-275-4446767,Ext.400
Application for Determination of Water Adequacy
Instructions
T. 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 on Applicant: lei1\ ' Date:
Mailing Address: So) wul G i ua Phne:
sw' 310 - 761 —
Parcel Number: 31101- 1 J'' q t)o 13
Type of Water System Reason for Application
®, Public/Community Water System (2 or more Building permit
connections) ❑ Division of land:
El Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
El (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. f ,l
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
SEP 2 4 2026
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 2— services.There
are presently 2—connection(s) in use.This will be the Z 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 t P� Phone [. 7.rL 9aI _$y
Signature of Water System Manager Date 9 _Z3_ 2 02f
This form may be scanned and available for public view at www.masoncountywa.gov
J:IEH Forms\Drinking Water Revised 05/08!2024 Pagel of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft.
El Well capacity Test(attached to application) 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
El 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
e �
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).
Re iewer's Signatures: ((��
Environ. Health: Date G (V't z
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 or2
Thurston County Environmental Health
412 Lilly Rd NE ♦ Olympia,WA 985O6
360 867-2631
THU i
COLIFORM BACTERIA ANALYSIS
Dale Sample Collected' Time Sample County
r ZZ J 20 W Collected IsMAM 0
Month Day Year
Type of Water System(check only one box) ❑ Private Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID# —_
System Name:
ContactPerson: to 1 ;L.-*'-'
Day Phone:(_7(y. ) -10 4 U1 Cell Phone:(
E-mail: A(' cC E)N-V /L C�vkc.�1 <•• Eve.Phone:( )
Send results to:(Print lull name,address end zip code or ema1 address)
3 u W�l14cL 4�w k 6rur. Suite z
SAMPLE INFORMATION
Sample collected by(name): IA,..
Specific location or address where sample collected: Special instructions or comments:
lJ1 se -v)-*7 /ç
g'tic,l,kati f..�A-
Type of Sample(must check only one look 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.col—GWR(AIP)
1.Fecal—Surface,cwr,spiing (mxneraaon) Unsatisfactory routine lab number.
Flllered:Yes No
❑Assessment Monitoring(AIP) Unsatisfactory routine collect date:
❑Other I I
S
4;W Sample Collected for Information Only
Investigative Construction I Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E,caG present ❑E,colf absent
No liform detected
}
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform 1100mL E.cok 1 t00m1.
Fecal Coliform 1100ml Enlerococcl 1100 ml.
Method Code: M 92238 ❑SM 9222D QDie and Time R
❑SM 9215B ❑Enterole 2b D1 '
Dale and Time Analyzed: - Dale Repo ied. (,
Sample rmrber(OOH number pbs We dg�s) Lab Use Only:
DOH Form 11331319(revaed 11123)