HomeMy WebLinkAboutWAT2021-00109 - WAT Application Esc f4lki9
ArX?f_ 00/09
WAT
415 N.61"Street
MASON COUNTY Snaton,wA98584
COMMUNITY SERVICES eltom:360-027SA4/O,Ext.400
B elfau:360-275-0467,Ext.400
a,;emgrrinnq[ me.n;xwxscanrnwrcy x.,nx EIma:360- 2-5269,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 a2proved building site plan must accompany this application.
Part 1: Applicant/ Pa.1rc}el Ide/lntification
Name on Applicant: UOhg 17NsCb Data:
Mailing Address: Pd to. /012 Phone: Eso - 7-f I Z2(1
Parcel Number: 17-3 I If'NM-Oao 70
Type of Water System Reason for Application
❑ Public/Community Water System (2 or mom 8( Building permit
connections) ❑ Division of land:
9 Individual water source(one connection), #of Parcels? SPL
Elf Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have mom than one residence connected of water system below if applicable—no
to this well, check the PubficlCommunity 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)
❑ 1 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
This form may be scanned and available for public view at www.co.mason.wa.us.
I
Retied 4/L2018
E\ER Forms\Drinking Water
Individual Water Well
❑ Water well report(attached to application). Depth fl.
❑ 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-dam and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14_15_16_22
Water use or limitation recorded................................... N/A Yes_
WellDrilled ............................................................... Date
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)
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,This 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).
Reviewer's Signatures:
Environ. Health: -ne 101�-"r 0610
1
Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Pape2 oft
II I Thurston County Environmental Health
412 Lilly Rd NE
Olympia,WA 98506
AL
380-887-2631
COLIFORM BACTERIA ANALYSIS
Oak Sample Colllbotbtl Time Sample County
11 �2, �f.J Collected Uy✓
(�. 4gom, Dec
aam °" Year 14202
Type cfWaler System(check only one box) •mute Househoki RFC
B/Vg0
❑Group A ❑Group B ❑Other
Group A and Group B systems-Provide from Water Facilities Immnkry(WFI):
iD#
System Name:
Conkd Person: p A.US C U
Day Phone: 1 Call Phone: 0) 4112
E4nail: ErePhom:( )
To resoe Mhll e.nam address aid alp ocdea area acdow
!J 15 dAJ5 Cry�( /
Yq VI
SfS&S
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SAMPLE INFORMATION
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G/ 1Vrony ad*�0 wn��r� Spedal inawdbns arcamrenta:
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Type of Sample(must check only one box of#1 thmgh#4lMad below)
1.❑Routine DisMbuUon Sample 2.Repaal Sample(after unw.mudne)
Chionnated:Yes_No_ ❑OleteLution System
Chlorine Residual:Total_Free_ Chlorinated:Yes_No_
3.Raw Water Source Sample Chlorine Residual:Total_Free_
❑E.we-OWR(ArP)-
❑Fecal-wuez,awl.sppoa(�ume ) Unsaterebrymumolabn ndso,
Fared'.Yes_No_
❑Assessment Monibmg(NP) Umnstafactory medne wllectdak'.
Doter
S
A(Sj Sample Collected for information Only
mmastgatlrx dC Come.clion)Repairs Other_
LAB USE ONLY DRINKING WATER RESULTS LA UBE ONLY
❑Umattahctory Total Cordmm Presentand Satisfactory
❑E.W present ❑Ecofl absent o IiformdebiAW
Replacement Semple Rquimd:
[-]Sample be old(>30 hoursl ❑TNTC ❑
Bacterial Density Rewlts:Total Coliton /10gM. E.w# /100m1.
Fecal Colifo NOON Entatawwl nog mi.
Mwori Cade'. M92238 ❑SM92220 Dale and Tura RewiredlI
SM 9215B ❑Enkrolert® a
Dale ale Tme Analysed. -a Dela Repnt - >)
Sime.rtM'DCH numhr qus fireegNl IaDUse Only
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