HomeMy WebLinkAboutWAT2026-00194 - WAT Application - 9/29/2026 WAT 2026-00.194
( A MASON COUNTY 415 N.6th Street
SheltontJ ,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 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: Kyle Cryder Date: 8/20/2026
Mailing Address: Po Box 129 Olalla,WA 98359 Phone: 360-620-9960
Parcel Number: 222237790021
Type of Water System Reason for Application
® Public/Community Water System (2 or more M Building permit
connections) O Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well O Boundary line adjustment
❑ 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: (257(.2 1 (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 3 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 limis set by state and local regulation.
Print Name of Water System Manager �J '(/ ,2 _c Phone SAO ' °9'
Signature of Water System Manager Date C ` _____
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
Group B Water Systems
ll Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ 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
❑ 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)
X 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.
H Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
9/29/26
Environ. Health: I Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
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(360)779-5141 j COL1FORM BACTERIA ANALYSIS FORM
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Date Sample Collected Time Sample County
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Mona pay Year :0_❑
Type of Water System(check only one box)
❑Group A Jgj Group e ❑Other _. a_ __.
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person:
Day Phone: Cal Phone:
Email: ` r t —r' A
Send results to:(Pdnt full name,address and zip cod I
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SAMPLE INFORMATION
Sample collected by(name):
Specific location where sample collected: Special instructions or comments:
Type of Sample(check only one box)
1. Routine Distribution Sample(A/P) j 2.❑Repeat Sample(AJP)
Chlorinated:Yes ❑ No, (from distribution system after unsat.routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total_Free•_
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Chlorinated:Yes No
❑Triggered (NP)
Chlorine Residual:Total_Free_
❑Assessment(NP)
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❑ E.coli ❑Fecal Filtered Yes_No
5.❑Sample Collected for Information Only: [Ii Private Refldence ❑ Repairs
LAS USE ONLY DRINKING WAlER RESLJLjS ONLY
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E.coli present ❑E.coli absent
Bacterial Density Results:Total Coliforrn mpnl100ml.E.eoli mpnf100mi.
Fecal Colifom3�cful100ml. liPC cfull ml.
Replacement Sample Required: ❑TNTC 0 Sample too old
❑ Sample Volume Q Damaged Container ❑
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