HomeMy WebLinkAboutWAT2023-00060 - WAT Application - 6/6/2023 ' WAT 20Z.S - COG6V
415 N.6t Strout
;,,,•`� -`,,.{ Shelton,WA 98584
MASON COUNTY Shtlton:360Shelto , 9 584
a COMMUNITY SERVICES lijelton:360-275-4467,Ext.400
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`,: 1• ;�, Elan:360-482-5269,Pact 400
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Application for Determination of Water Adequacy
Instructions
1, Complete Part 1. No determination can be ma de until tee type Part
of water connection tutliized.
2. Complete only the portion of Part 2 applying to
3. Submit 4. An approved completed
buiildingsitapplication,
e tplan must accompa y this ppli ncation r review.
.
Part 1: Applicant!Parcel identification 2,y,Z3
Name on Applicant: 1dtARQ4 or t') Po-A0 j D Date:
Mailing Address: (t3o E, trlQt�1Vt O ) Ave
Phone: 711 6-6----
Parcel Number:
3a,ta.11)oD Ic't 3 360-7:23 I,Lf 07
Type of Water System
Reason for Application
Building permit
Public/Community Water System(2 or more 0 Division of land:
connections) SPL
❑ Individual water source(one connection), #of Parcels?
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ 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
Name of Water System: L�k
e_ �l m e,ri cl'•- Wtt ca e r-
Water Facility Inventory(WFI)Number: W 41 56 7 (write'none"for two-party)
)4 ,,P l��,�
i am the manager of this�wnteedion(s)In use,This tem.The water w utbe t e has
� D connection. services.There
are presently 1 6?
0 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. 3f1
Print Name of Water System Managert('5 p)A''L'"'�/)VI)('ih Phone 366- y ('^
28 Z 3
Signature of Water System Manager
MAUL Date 6,-9
This form may be scanned and available for public view at www.co.m o s•
J:1BH Forme\thinking water Revised
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/planninq 14n 15(1 1 617 221—J
Water use or limitation recorded N/A I I Yes n
11 Well Drilled Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
4 0 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)
NIf.,T
'Satisfactory Determination:
his 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: (2=- Date 6 ( (-z v
`°'2
CSD Director: Date