HomeMy WebLinkAboutWAT2023-00157 - WAT Application - 3/3/2023 y
,�,i1, MASON
1�1�s p GCS -202 3 -7-
NCO - OOi57.
COMMUNITY COUNTY
S \_�'��'� Building,Planning,Environmental
nVrr� SERVICES
Shelton:(360)q2, m 867� q 15 N 6rhStreet,
entall�ealth,community
ext 441 Saie t, Bldg g Shelton Neap,
00 °' Belt
Instructions Application for FAX �36p)427_�78jX 40p86Elma:
2. Co mplete pan 1 Determination O (360)gg2 526g em 400
of Adequacy
3. Submit
only the NO deterrn;natio Ad q�lacy
part mit etecor feted portion llcl f pan determination
be made
�� Applicant/ "' h att until p
with applying to the type an is full
Name°"ApPlicant: Parcel Identification
dentificati attachments to the health de a stem ut72ed.
Mailing Ad Scu, Oh �ment for
Address: �- ��i���r'pr review.
Parcel Nu C� sr S LL /Q UOY
Number:: ' i�o,,� , Z3 C GSGp?
3� 8 E Date
{� Type O--
d� Public/CO S C—a(�� l Fj� hone: 3 ` Z 3
of Water
tun, System (�O z 7S-6
Individual
unity►�yater SystemZ.S�
dividual
(2°rmor water e
Other Spring/surface
(one connection), Building
forApplic
(explain) g/surface Division
permit-PI)I Application
water
ll
"0f land: �Z02-3 - QG75i
O #of Parcels?
to
thisu we// c have heck than one residence
8°und
Ystern box °k the Pub/ic/S�denoe con p Other arY line adjustment
d- SPL
'art Public/Common/4/wateed 4 Replacement(please
meat
gar ie e theW Water
System Information
nf requsystired)
be/ow if indicate
or►natio ed) applicable_ name of water
section appropriate n
priate for the type of w no signature
Name of Wat water system being er System: public W
Water Facilit eC ater Sst evaluated:
1 1 am the y Inventory(WFI)Number:
wA�'� �, stem
There areaeSereitly f this Water system. sc?s�� '� T' � I
m the .2.. m. T (write G Y.Z Ne pgy
of connection manager
o f this system.system.Th )/Hater system has "none"for two-party)
thison s em This °n se• s been Y)
water is change: system(i.e.:recreational
will This will be the approved for-�d�+
of the water
is able Hal to fulltime).be to upgrade
watere ndi fconnection.
o following
o services.
system or willing to ;
orchange
lame of at Ysfe and y limits set provide water to Please indicate on the the use of an
Water system Y state and�this (these)co ollowin9!in hestin9
re cal re e t
of Water S Manager regulation.
nature
System Manager )without
exceeding the
��`��S Phone
Go .
may be scanned and _ A*� Date a _ 7S': 3ov8
available for Public view° Revised3�
n the 19/202 Mason county 1
ty Web site. Page 1 of 2
Individual Water Well
❑ Water well repreport(attached to a
� Well ca AAlicatiPPlication). Depth
pacity Test(attached to application)
on)
The well driller often performs well capacitygPm
from these testsllerare per noted onm the water well regAd w tests at the time the well is constructed.
If the water well report cannot be located byport' Results from these tests will
have a ty test, a well the applicant or if the water well report
Results
recovery data,c capacity test, whichbe accepted.
must be performed byProvides stabilization of draw-down does
�d not
a licensed contractor.
C1 Satisfactory bacteriological test(attach to application).
Individual Spring/Surface Water
0 WDOE permit
(attach to application)
❑ Method of disinfection
0 I have reason to believe that this water source can
provides water at a rate of 2 gallons
provide on the t ast )gallons
per minute based on followingper da
observations. y' and/or
Author of Statement
Relationship to Applicant
Date
Departmental Use Only: Do not write below this line.
Part 3: Mason
County Public Health Evaluation
Satisfactory Deter
Applicant's water supplyDetermination:
lminaon does ot dd esaparade
adequate to meet the needs of its intended
deter inatiion does in the future,
regulations. adequacy of the distributions use. This
Recommended the utu approval guarantee compliance with all applicableppli guarantee E adequate resource
r i
regulations.
ns. Re inatme dof Adequacy indicates re de, supply of
requirements mayquacy for Buildingrequirements of Sanitary E water resource
apply Chapter 36.7 Permits are satisfied.ry Code, Title 6, Chapter
OA RCW. Additional Growth Management
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 e7
`.[:H For Drinking Water
This form may be scanned and available for public
Revised 3 s
view on the Mason County Web sit Pa e
e.
2 of