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Home My WebLink AboutWAT2023-00087 - WAT Application - 7/18/2023 WAT 2073 - 000 87 / . MASON COUNTY 1 @ ) COMMUNITY DEVELOPMENT }i'/ Permit Assistance Center,Building,Planning 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 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: Michael & Bobi Jo English Date: Mailing Address: 4280 N LAKE CUSHMAM RD Ho Phone: 4. 623-764-3786 Parcel Number: 222205200012 Type of Water System Reason for Application Ei Public/Community Water System (2 or more ❑ Building permit BidZ0Z3 —O 1.f 6S connections) 0 Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water El (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. IMNI Part 2: Water Connection Information ix p • JUL 1 8 2023 Complete the section appropriate for the type of water'connection beingq.v. 4ated: RECEIVED Public Water Ste �11r. Name of Water System: T-A Po tit i ;;;wsi AiW-4- Lk,.V 8 Water Facility Inventory(WFI) Number: t6 1 isk. I ors ) 6 (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. J;SI 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: (L6(_,agA>-\0 >J ra iltiS1AtiNTIAt_ 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 stat and local regulation. Signature of Water System Manager 7 Date --S" 2-3 —F — SLoYt G-00,1 0 6vA-T6,(2- W.) .i . ,6o-7 3) - 2_23) This form may be scanned and available for public view at www.co.mason.wa.us. .1:gill Forms\Drinking Water Revised 1/25/2018 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) Development within which WRIA http://gis.co.mason.wa.us/planning 14_ 15_16 22 Water use or limitation recorded N/A Yes Well Drilled Date Individual Spring/Surface Water ❑ WDOE permit (attach to application) 3 0 Method of disinfection 0 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 adeq4pgkof water indefinitely in the future, or guarantee compliance with all applicable WDOE water resource reg 1 !;6 Recommended approval indicates requirements of Sanitary Code, Title 6, Chapter 6.68.040-Determinatic Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapt0 36.70A RC . 4f �� 0 W Unsatisfactory Determination: C0// 4 2023 Applicant's water supply does not appear adequate to meet the needs of its intended use for the trifNyiftq 044, reason(s). O�.4 4/7- Fq lTy Reviewer's Signatures: a 7� Environ. Health: 02-------- Date //WW 2j This form may be scanned and available for public view at www.co.mason.wa.us. Page 2of2