HomeMy WebLinkAboutWAT2021-00250 - WAT Application - 7/10/2023 1,00- zo ( - oa a o
JVL 1 2 2023gN
soN coU �
t ENED Public . -'' Health
Always working for a safer. healthier Mason County
JUL i u 2023
PO Box 1666,415 N 6th Street, Bldg 6, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •3 Belfair. (360)275 4167 ext 400 C• Elma: (360)482-56gxt0 Alder Street
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: \'!(YVe5 V Date: 7/,rj,L c Q 3
Mailing Address: yQ D 1e .QNilf h,'4 hone:: .2r 3 - Sgo ( 31
Parcel Number:. ,.9a j'3 - sz..fro !(3\ y
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 0 Building permit -?Act Z023 "607322--
connections)" 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
0 Other(explain)
0 Replacement (please indicate name of water
if you have more than one residence connected system below if applicable-no signature
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:
Y. (( ` Public Water System.i i_ ,�,
Name of Water System: 1 1 `` i d (Pa -e-4
Water Facility Inventory (WFI) Number. S . J i C a.
(write"none'for two-party) 915'services.
`i. I am the manager of t waer system.The water system has been prov d for
There are presently lk+ connection(s) in use. This will be the 9connection.
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 I' asset by state and local regulation.
Signature of Water System Manager Date .
Revised 7f2013
Page 7 of 2
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
qpd.
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).
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
In addition to providing the above statement, the applicant will need to arrange an on-site
inspection by Mason County Public Health prior to determining adequacy.
Departmental Use Only: Do not write below this line.
Part 3: Mason County Public Health Evaluation 0 XSatisfactory Determination: t AUG 3 Q
Applicant's water supply does appear adequate to meet the needs O�, t j&4 use. 023
1vIYThis determination does not address adequacy of the distribution system, guaranty�ON an adequate supply of water indefinitely in the future, or guarantee compliance wif ill FtyT"`HFAtr
applicable WDOE water resource regulations. H
❑ 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 Signature: Date OW�/��1
-•sed 742013
This form may be scanned and available for public view on the Mason County Web site. Page 2 of