HomeMy WebLinkAboutWAT2022-00328 - WAT Application - 5/22/2022 - MASON COUNTY
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I. ��'� „ COMMUNITY SERVICES
jy _ y Building.Planning.Fmronmental Health,Community Health (
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415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions 's ` k-, , Ct C C C-� C (
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: .--ri vk Ratsv t Date: S /2-Z(Z 2.
Mailing Address: $21 L. 4e i'St-titvt, (,Awl " I4tJPhone: ( '5 ) 2 09-575P
Parcel Number: 22 01 0 5 C1C00 2-S I
Type of Water System Reason for Application
VI Public/Community Water System (2 or more A Building permit
connections) 0 Division of land:
0 Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
0 Spring/surface water
0 Other(explain) 0 Other(explain)
0 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:
Public Water System
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Name of Water System: /1MMMOJ(=•-t1/re •$1{�/1�'1)!�y f./
Water Facility Inventory(WFI) Number: ci—.t. a 70 f'
(write"none"for two-party)
am the manager of this water system. The water system has been approd for/.yam'services.
There are presently 4/e 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 � �/�� ��/f Date l
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised I/25/2018
I
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.
O Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
IDevelopment within which WRIA http://gis.co.mason.wa.us/planninq 14 151.__I 160221_j
Water use or limitation recorded N/A Yes!
Well Drilled Date
Individual Spring/Surface Water
I0 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)
Satisfactory Determination:
This determination does not address adequacy of the distribution system, guarantee an adequate supply of
ater 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: 611 I Date — I 1 ti
2 or
CSD Director: Date