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Home My WebLink AboutWAT2023-00110 - WAT Application - 5/15/2023 2 , WATaoa3 - OD ID O I MASON COUNTY ECEIVED COMMUNITY DEVELOPMEN Permit Assistance Center,Building,Planning MAY 1 5 2023 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360') :.: 2epztreet FAX(360)427 7787 ENVI RO f�'M E NTAL Application for Determination of Water Adequacy HEALTH 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 Applicant44J/4----f 1747-- Date: ^� c _ Mailing Address: 1 E, et.4 V2,cei• Phone: 3-S — (J Zj Parcel Number: 2_270 - L----6200W4L7 Type of Water System Reason for Application (f Public/Community Water System (2 or more J'Building permiteLQQDa3- 005 r connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other (explain) ❑ 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. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: -nir'1k2.o21 4 t4-vCG.,�-, Water Facility Inventory (WFI) Number: (write "none"for two-party) ❑ 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. ❑ 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 limits set by state and local regulation. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa,us. ]:\EH Forms\Drinking Water Revised 1/25/2018 .. -.. WAT _ MASON COUNTY COMMUNITY SERVICES Sulking.HrnY+¢E notion montd Nrlth,Community lMdth 415 N 61'Street,Bldg 8,Shelton WA 98584, • Shelton:(360)427-9670 ext 400 +i Betfalr.(380)275.4467 ext 400 4 Elma:(360)482-5269 ext 400 • FAX(360)427-7787 Application for Determination of Water Adequacy Instructions 1 Lo 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:\ fmy' ino-4.uln ..P,1 V1 Date: YJ/ 3 / Mailing Address:{y `dZ A-01" Art_ Phone: c5 3 C •01 Parcel Number: a a-(Dt$' (pc bct to c ctit,,a, (-4-) .1 c(L{c Type of Water System Reason for Application APublic/Community Water System(2 or more Building permit connections) 0 Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ 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. Part 2: Water Connection information Complete the section appropriate for the type of water connection being evaluated: l Public Water System Name of Water System: 7M ,1(44r 6 ^/4/ (/' 4 Water Facility Inventory(WFI)Number: ef�3-7°! a (write"none"for two-party) V � v am the manager oft�fs water system.The water system has been approved for( Y services. There are presently 'i43 connection(s)in use.This will be the `1ltf 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)connections)without exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager 4 Date -3 a� •This form may be scanned and available for public view at trvww.So,rev 1ised 20 8" J AEN Forms\Drinking water 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://giss.co.mason.wa.us/pianninq 14n 1 Sn 16n 22rn Water use or limitation recorded N/A 0 Yes I I Well Drilled Date Individual Spring/Surface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection D 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 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. LI Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). rmotR wer's Sign es: .oOS14 Environ. Health: Date 7 /L o?�.T 2of2 CSD Director: Date