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HomeMy WebLinkAboutWAT2023-00172 - WAT Application - 7/18/2023 RECEIVED WAT aOa3 - OC)l JUL 18 2023 r ''y/1 ENT t~ , 'j�t /►� 415N.6`hStreet M yy�++ /@� '1 Shelton,WA 98584 , r(19 -7. ) COMMUNITY SERVICES F,LALTH Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 Building,Planning,Environmental Health,Community Health Elma:360-482-5269,Ext.400 Application for Determination of Water 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 connection utilized. 3. Submit completed application,with any required attachments for review. 14. An approved building site plan must accompany this application. Part 1: Applicant/ Parcel Identification Name on Applicant: Jack Jensen Date: 06/06/2023 Mailing Address: 121(fStandstill Dr N Phone: 509 539 3643 Parcel Number: 422055200011 Division - block - lot: Div 19 / Lot 11 Type of Water System Reason for Application (� XI Public/Community Water System (2 or more © Building permit'6ti,)Qoa-5 - c08 C.. connections) ❑ Division of land: ❑ Individual water source (one connection), # of Parcels? SPL ❑ Well ❑ 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: LAKE CUSHMAN SYSTEM 5 Water Facility Inventory (WFI) Number: 035290 (write"none" for two-party) ❑ I am the manager of this water system. The water system has been approved forli services. There are presently connection(s) in use. This will be the connection. E 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: New single family residence 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. Print Name of Water System Manager JESSE MATHEWS Phone 360-877-9668 Jaffe Mathewr Date 06!08/2023 Signature of Water System Manager - This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 4/27/2021 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://qis.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 ❑ 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 adequatels �9f� water indefinitely in the future,or guarantee compliance with all applicable WDOE water rsource regulatibrkl Recommended approval indicates requirements of Sanitary Code, Title 6, Chapter 6.68.O4De;errminaaion of Adequacy for Building Permits are satisfied. Additional Growth Management retuti4r�ments ma r yha ter 36.70A RCW. UiviyFNV Unsatisfactory Determination: D R�NMFNTq Applicant's water supply does not appear adequate to meet the needs of its intended use for t1f following HEALTH reason(s). ,14Reviewer's Signatures: W -f(ZO(Environ. Health: ;t/ Date 2-3 This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2