HomeMy WebLinkAboutWAT2023-00024 - WAT Application - 1/21/2023 lift
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WAT_02? - 60' l l
MASON COUNTY
COMMUNITY SERVICES
• Building,Planning Environmental Hegth,Community Health
415 N 6th Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 + Belfal (60)245 44677 ext 400 4 Ems:(360)482-5269 ext 400
FAX
Application for Determination of Water Adequacy ENV/Ro��i,�,�
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Part 1: Applicant/ Parcel identification ,1 j y / 2 3
Name on Applicant (,h4r r'r•S cirri, fFr nc, Icer -e't Date:
Mailing Address: •17,U3 /Z/J Avc E •i1af47,it.i4 Phone: 253 CV- 7fo1
' Parcel Number: ,32109 ^.7l-/oo30
Type of Water System Reason for Application
IX Public/Community Water System (2 or more tar Building permit
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ 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. R� c
Part 2: Water Connection Information C` V
Complete the section appropriate for the type of water connection being evaluated: JAN 3
Public Water System /5 �VAid
er c
Name of Water System: C C21-4A/y S uXF a 140 W47ZC
Water Facility Inventory(WFI)Number: /99-0 80 -
(write"none"for two-party)
0 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.
71 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 Tine the nature
of this change: of(F REWA' ,rn4/ 72k PO`4. 77fi7i
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 0.9 �i� --_ Date 0/-25 -°23
This form may be scanned and available for public view at www.co,mason.wd a.us.
.
J:\EH Forms\Drinking Water
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://gis.co.mason.wa.us/planninq 14_- 15 16A 22_
Water use or limitation recorded N/A Yes
Well Drilled 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
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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).
Reviewer's Signatures: ��
Environ. Health: Date /3 /C 1 ce Z0 Z
This form may be scanned and available for public view at www.co.mason.wa.us.
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