HomeMy WebLinkAboutWAT2023-00124 - WAT Application - 4/25/2023 1111
wAT 42'2 - 012.
i 15 o''Stirs",
{A'.\p�ji
401 1t.�`n!\COUNTY
1 Sixltxt ttit-i-7-ae.70.Eat.400
COA1�fU\Il l'DEVELOPMENT ritt.�t *►r'-5.2scr.F".400
q.w.S ayy'.f.�C<\.+'H+P..Y(.t°:`r''Y
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1.-No determination can be maadunlit Part 1 is fully
utilized.
2. Complete only the portion of Part 2 applying the type
of water
for review.
3. Submit completed application,with any requiredan attachments
icatioo.
4, An a roved buildi site Ian must accc�m_p� ��---
Part 1: Applicant/Parcel Identification
Applicant: 6-ft'r4lek`l- tren AS1 Date: _9_4_ _g.5 — a_�3
Name on App y�� � / q D 1--..
Mailing Address' t/� -� C 5 t..�t- ri"`O' o c �a_2!_L 3/--
Parcel Number ,i`�- pdJ-.33-_i Za —q_q2
Reason for Application
Type of Water System �A ��,,,,//�� 22 �Ql-OZfJ
Suildtng permit '1t3ld�vJ
PublidCommunity Water System(2 or more 0pivi5ion of land
connections)
>4 of Parcels? SPL!_
LC Individual water source(one connection). tine adlustmenl
0Well U Boundary
0 Spring/surface water 0 Other(explain)__, _----
C Other(explain) o Replacement or Remodel(please indicate name
of water system below if applicable-no
If you have more than one residence connected signature required)
to this well,check the Public/Community Watcr �� ��
System box 00607
Part 2: Water Connection Information
Complete the section appropnate for the type of water connection being evaluated'.
Public Water System
Name of Water System: t. Cc'- ---
Water Facility Inventory
(WFI)Number.
(write'non&for two-party)
roved for
P1 I am the manager of this water system.The water system has been app connection.
There are presently __connection(s)in use.This will be the
❑ 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(thes connection(s)without exceeding
ulation
r g .
the limits of the water system or any • 1 se Late and local4...
�
Date
Signature of Water System Manager —_ _
This form may be scanned and available for public view at www.co. sonawa.us.
Ret;isad 3.'�'Zil1 x
1'EN Fo m.',chinking Watrr
Krn_4you@yahoo.com
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
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)
atisfactory 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).
C�Re/vliewer's Signatures: Q
Environ. Health: b r r 1P4TQAIN)
Date G ('-2" ) (-u•
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATER FACILITIES INVENTORY (WFI) Quarter: 0
Updated: 06/20/2023
eir'r W rsl�gton State Department of FORM
oHealth ONE FORM PER SYSTEM Printed 6/20/2023
oia;ionoJ C„t•imun,r„1.,!„fr.,,,,, WFI Printed For: On-Demand
nfte of Dri„king ltiirter
Submission Reason: Contact Update
RETURN TO: Central Services -WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@doh.wa.gov
1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE
37351 Q SPENCER RIDGE MASON B
6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS
FLOYD R. SAWYER JR SPENCER RIDGE WELL ACCOUNT MANAGER
4833 E STATE ROUTE 3 FLOYD R. SAWYER JR
SHELTON,WA 98584 4833 E STATE ROUTE 3
SHELTON, WA 98584
STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE
ATTN ATTN
ADDRESS ADDRESS
CITY STATE ZIP CITY STATE ZIP
9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION
Primary Contact Daytime Phone: (360)731-8870 Owner Daytime Phone: (360)731-8870
Primary Contact Mobile/Cell Phone: (360)731-8870 Owner Mobile/Cell Phone:
Primary Contact Evening Phone: Owner Evening Phone:
Fax: E-mail: fsawl@msn.com Fax: lE-mail: fsawl@msn.com
11.SATELLITE MANAGEMENT AGENCY-SMA(check only one)
x Not applicable(Skip to#12)
0 Owned and Managed SMA NAME: SMA Number:
Managed Only
Owned Only
12.WATER SYSTEM CHARACTERISTICS(mark all that apply)
0 Agricultural 0 Hospital/Clinic Residential
Commercial/Business 0 Industrial 0 School
Day Care 0 Licensed Residential Facility 0 Temporary Farm Worker
0 Food Service/Food Permit 0 Lodging 0 Other(church,fire station,etc.):
El 1,000 or more person event for 2 or more days per year 0 Recreational/RV Park ---
13.WATER SYSTEM OWNERSHIP(mark only one) 4. STORAGE CAPACITY(gallons)
E Association EI County 0 Investor 0 Special District
Ei City/Town 0 Federal ixt Private 0 State
15 16 17 18 19 20 21 22 23 24
SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
rn 23
m
m xi z m o
LIST UTILITY'S NAME FOR SOURCE 1- 2 m cn _ 1
AND WELL TAG ID NUMBER. < 0c pp = > m
N 0 D N to -n Z I r D O °'
c Example: WELL#1 XYZ456 v at O rn m m at r — c v <m m
m m m m t� m rn m O 05 D— 'a z -a
mIF SOURCE IS PURCHASED OR INTERTIE r r z z D m O m m m A r r A L) O
Z r r N G1 O * 3, 0 D y 23 1 z D 0 0 z4 EA m c < 73
c INTERTIED, SYSTEM -n n 'n r D D r -I z O m m z D P D z _, T O z r C) 3 z D
3 LIST SELLER'S NAME ID m m m _ m m -1 -1 m m m z z x O — _� 2 = m at 5 O =i co = z
a r r r z r r m rn xi m z D n m z 0 0 0 m rn m z O m C)
A Example: SEATTLE NUMBER r v 0 0 0 v A A -< XI -1 r < o m z z z A -c z m rn z x - m
SO1 WELL#1 NO TAG X X X 167 37 NW SW 33 21N 02W
r1r.I nn4 Al /rl... nC,n-, .-.i.. .-. 1