HomeMy WebLinkAboutWAT2023-00033 - WAT Application - 3/9/2023 i
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WAT0o?�)a�- o�3�
MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health.Community Health
415 N 6tn Street, Bldg 8,Shelton WA 98584, E
Shelton:(360)427-9670 ext 400 ❖ Betfalr.(360)275-4467 ext 400 •:• Elma:(360)482- L.. E—"
FAX(360)427-7787
Application for Determination of Water Adequacy MAR - 2023
Instructions 615 W. Alder Street
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 ENVIRONMENTAL
Name on Applicant: Vincent Kurz Date: 02/06/2023 HEALTH
Mailing Address: PO Box 2655 Belfair, WA Phone: 5Q9-435-2481
Parcel Number: 22221-53-00030
Type of Water System Reason for Application
V Public/Community Water System (2 or more 0 Building permit
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ Other(explain) c,/
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. SL.•910OR3_Wl 69(PPart 2: Water Connection Information �V
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Twanoh Falls Beach Club /�
Water Facility Inventory(WFI) Number:boll-T- ' 0 g) e
(write"none"for two-party)
0 I am the manager of this water system.The water system has been approved for 341) 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: (Z-it,f L .tiMf0-3 i Nti o r-)U i-Ai-e- 13-0/tl it
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 t by st e and local regulation.
Signature of Water System Manager Date 3 ---`V -2-4 2_3
This form may be scanned and available for public view at www.co.mason.wa.us.
J_\EF;Forms Drinking Water Revised 1/25/2018
Individual Water Well
F ❑ Water well report(attached to application). Depth ft•
❑ Well capacity Test(attached to application) qpm .pd.
The well driller often performs well capacity tests at the time the well is const 'ed. Results from
these tests are noted on the water well report. Results from these tests wi •e accepted. If the water
well report cannot be located by the applicant or if the water well report ...es not have a capacity test,
a well capacity test, which provides stabilization of draw-down and r- overy data, must be performed
by a licensed contractor.
In Satisfactory bacteriological test(attach to application).
Water Resource Inve•• ory Area (WRIA)
Development within which WRIA http://ais.c. ason.wa.us/pianninq 140 150160220
Water use or limitation recorded N/AL1 Yesj I
Well Drilled Date
In•' idual Spring/Surface Water
❑ WDOE permit(attach to a••lication)
❑ Method of disinfection
❑ I have reason to •-lieve that this water source can provide at least 800 gallons per day; and/or
provides wate .t 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,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:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures: '7/(7(7
Environ. Health: Date j/C 00
2of2
CSD Director: Date