HomeMy WebLinkAboutWAT2026-00183 - WAT Application - 9/29/2026 WAT 2026 - 00183
.. 415 N.6'h Street
MASON COUNTY Shelton, WA 98584
COMMUNITY SERVICES Shelton: 360-427-9670,Ext.400
Belfair: 360 275-4467,Ext.400
Building,Planning,Environmental Health,Community Health Elma: 360-482-5269,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: �i Vi eta- ( I'77 c e--tt- Date:
Mailing Address: /O0 E. Le j-1ki- L v� . Phone: 2 O' . j a y
Parcel Number: I 2L24 9tô t )
Type of Water System Reason for Application
CN( Public/Community Water System (2 or more Is' Building permit BLD2026-00823
connections) ❑ Division of land:
El Individual water source (one connection), #of Parcels? SPL
❑ Well El 13nundary line adjustment
❑ Spring/surface water
O Other (explain) El (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:
lPublic Water System
Name of Water System: ) 1 Pew Lc1 e S1" GwoA \N \\
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. —� '.�
Signature of Water System Manager Date�5 Z�
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EI-1 Forms\Drinking Water Revised 4/4/2018
Group B Water Systems
1S! Satisfactory bacteriological test within last year(attach to application). 09/23/2026
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.
Ll 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:
Environ. Health: Date 09/29/2026
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
Thurston County Environmental Health
1 m'
412 Lilly Rd NE C Olympia,WA 98506
360 867-2631
THURSIiON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
q '^- 12O^'_ Collected /.� r
`{ [, [.t17 /�T SAM �' J S O/'V
Month Day Year
:VD ❑PM
Type of Water System(check only one box) 0 Private Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person:
Day Phone:( ) I Cell Phone:( )
E-mail:Teats 'rt.n G,e N$r.1.Lb(Y1 Eve.Phone:( )
Send results to: Print full name,address anc zip code or email address)
Zer - - 1110 . eS
F S : k C. S h e.t+b rJ ,>a t
co" pinnG.tlePnw.c.ew.
SAMPLE INFORMATION
Sample collected by(name):O 2af \C
Specific location or address where sa pie collected: Special instructions or comments:
11 E . Cer ke..c` . A
Gr ►ear WPIQgS�4(D
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.coli—GWR(A/P)
❑Fecal—Surface,GWI,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) sfac ory routine° ED
❑Other _ I /
S
4.XSample Collected for Information Only
Investigative 2 Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present O E.coli absent o oliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100ml. E.coli /100m1.
Fecal Coliform /100m1 Enterococci„ /100 ml.
Method Code: M 9223B ❑SM 9222D Date and T n-.e Received:
❑SM 9215B 0 Enterolert® t
Date and Time Analyzed: 3- 2-16 Date Reported i'
Sample Number(DOH"umber plus fve dgits) Lab Use 0r y:
D6-i Form#331-31b(rev'sed "3)