HomeMy WebLinkAboutWAT Application - 4/17/2023 T6V,C12,011-44-+
ECEIVED
MASON COUNTY APR 17 2023
� : '� ; COMMUNITY SERVICES
61 WAI
' W.
der Street
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Building,Planning,Environmental Health,Community Health
415 N 6'h Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4• Belfair:(360)275-4467 ext 400 •:• Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Determination of 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 system utilized.
3. Submit completed application, with attachments to the health department for review.
Part 1: Applicant/ Parcel Identification
Name on Applicant: it( utty 11ry Date: 3 --ZZ-Z 3
Mailing Address: )Z Phone:: j(Cr-2 Z.c'-Q 1f�
Parcel Number:: ,3 I Rom- 57- LOL'fi/y
Type of Water System Reason for Application
kg. Public/Community Water System (2 or more 151 Building permit j id 2o2 3. 00'40 9
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
❑ Spring/surface water r r �� r __ ^,',�
❑ Other(explain) lir O ._ r t,'r l-C�t ci�r,n 1Fr
0 Replacement .lease indicate name of water �
If you have more than one residence connected - •- iw if applicable-no signature a1
to this well, check the Public/Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI)Number: &f-1 l ( 3 •
(write"none"for two-party)
ex -,roc con neth) &
I am the manager of this water system. The water system has been app d ed for il$-1 services.
There are presentl„ fir/ connection(s) in use.This will be the. _connection.
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 s/stem or an limits et fly state and local regulation.
Signature of Water System Manager • % Date :_.) .
PEH Forms Drinking Water Revised 12/1/15
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This form may be scanned and available for public view on the Mason County Web site.
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_16_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
• •
Part 3: Mason County Community Services Evaluation (staff use only)
I 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
This form may be sca ned and available for public view at www.co.mason.wa.us.
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