HomeMy WebLinkAboutWAT2020-00081 - WAT Application - 3/1/2020 RECEIVED
WAT
MAR 18 2020
615 W. Alder Street(3tt03 . rt ,
Shsiton: 427�87Q ext aHb #+ axl 4 Erns:
FAX(3ll0)427-flei
Application for Determination of Water Adequacy HEALTH
Ins
1 1. No can Pa.t,
2. Complete only the portion of lMng to the type of waler
: 2 " application1 shy raqUkad attachments for ►.
Part 1: Applicant/Parcel identification
Name on Applicant: s'
_Date:
Mailing Address
Ph-one--
Parcel Number:
Typo of Water System Reason for Application
Amoons) Water System(2 or man Building permit
moo"
❑ Individual water source(one connection), `of land:
❑ Well #of Parcels?_____
sty.
13 Boundary Ibis adjuetrnent
O 9 ringhurrece water
❑ Other( ❑ od,er to
ffy use ++airw lwtatenc. �"� name
tothis s,.4 ofj 5p System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water aoflnec n being evetueted:
P�Watrr syst em
Name of Water System
Water F (WFI)Inventory Number.. _
(write"none"for two-party)
_
I am the manager ,eye,The w
There are q �oonr«ec l #.In us. 1� ► r S.
❑ tam the man
ager of this system.This connection will be to upgrade or change the uas of.,:connection on this system(is.:recreational to till S Indicate on the
of this change: - w dun
This Water system is able and
the units of ttte.water system or any Wlpp mtion.
drop
Signature of Water System ManstiVg gat.
' `torn may be scanned and a labia for� rat.
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(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://qis.co.mason.wa.us/planning 14__15_16_22_
Water use or limitation recorded................................... N/A_____N/A Yes
WellDrilled ............................................................... Date
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)
riatisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee. of
water indefinitely in the future,or compliance with elkresource regulations.
Recommended d approval indicates requirements of Sanitary Code,TItle 8.D of
Adequacy for Building Permits are satIsfied. Additional,Growth'Management requirements may fir. Chapter
36.70A RCW.
Unsatisfactory Determination:
Applicant's,w ter supply does not appear adequate to Trot the-new of its intended use for the following
mss)
Reviewer's SI a
Enron. Health: _�
CSD Director: Date 2 of 2