HomeMy WebLinkAboutWAT2023-00114 - WAT Application - 5/18/2023 • WA'I'aba.5-
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MASON COUNTY
1111 1r ‘ COMMUNITY SERVICES RECEIVED
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MAY 1 8 2023
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Application for Determination of Water AdequaccN'/IRON;yr�ENTAL
Instructions HEALTH
1. Complete Part 1, No determination can he made until Part 1 Is fully completed,
2. Complete only the portion of Part 2 npplying to the type of water connection utilized.
3. Submit completed application,with any required attachments for review.
4. An approved building site piton must accompany this application.
Part 1: Applicant/ Parcel Identification
l� r� / ! 3
Name on Applicant: Date:�'t `�'t �S
Mailing Address: rL. (1-A S T' keJ Phone: 34.0 - ro ?-11,-
Parcel Number: 7--2_("0 1 5°look
Type of Water System Reason for Application
Q'Public!Community Water System (2 or more 'wilding permit 6 Lo ao 023-
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ 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: -Pi)" Or%/4/r1 CJ,411}711A t/ C`4/)
Water Facility Inventory(WFI)Number: ee 370 f- /
(write'none'for two-party)
I am the manager of this water system.The water system has been a proved fo/'*Y services.
There are presently 9/ 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 system or any limits set by state and local regulation.
/71e
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised
Individual Water Well
❑ Water well report (attached to application). Depth ft.
❑ Well capacity Test (attached to application) gpnn 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.usiplanninq 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)
XSatisfactory Determination: � '
This determination does not address adequacy of the distribution system, guarantee an adequate Ai i f
water indefinitely in the future, or guarantee compliance with all applicable WDOE water resource reg
Recommended approval indicates requirements of Sanitary Code, Title 6. Chapter 6.68.040-Determinati
Adequacy for Building Permits are satisfied. Additional Growth Management requimients may .pJ. DChapte• o
36.70A RCW. JpN�, �U p
1 Unsatisfactory Determination: oU'Ik �O2J
Applicant's water supply does not appear adequate to meet the needs of its intended use for the Lt�f1/619,r,19
reason(s). U`/'q 411,
Reviewer's Signatures:
Environ. Health: / Date g/ /zo
171
This form may be scanned and available for public view at www.co.mason.wa.us.
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