HomeMy WebLinkAboutWAT2023-00174 - WAT Application - 8/23/2023 t._/—
WAT - 00174
f
415 N.66 street
MASON
nolo&WA MAN
COMMUNITY_SERVICES Shaw: Ex`400
&Hair3b0-27S.4467.Ext.400
Plawmg.Gewramemdal►w.e.Ca.o.M►tank Elise:360-4/12-5269.Eat.400
Application for Determination of Water Adequacy
Instructions
1. Cwnpli t M 1. No delermlnellon can be mods raid Part 1
2 ContlllMt one►the portion of Prt 2 sppkling le She Hype duller wmuollon Wind.
3. Subtle mripi-Md opploalion.with any required allealiments for rostra.
4. An saerovad butte eke plea mint aerie pang fhb appioaron.
Part 1: Applicant( Parpal Ids n /
Name on Applicant VA. is( .7I 1' 20 :-'a
Mailing Address: t . to • 2cs At 3
Parcel Number ,322ikat45• R_--L cA 4
04-1
ICPeof Water System for Application
ildConimunityty Water System(2 or more permit i�lG12o2�, cob
connections) 0 Division of land:
❑ Individual water source(one connection). r«of Parcels? SPL
0 � water 0 Boundary line adjustment
❑ other(explain) ❑ Other(explain)
0 Replacement or Remodel(paw indicate nouns
if you haw more than one residence connected of water system below if applicable-no
to this wet chock the PubllciCornmwllryy 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: 5ij CR E 4 t
Water Facility Inventory(WFI)Number 786,ro-r (write'none"for two-party)
,g' I ern the manner of this water system.The water system has been for servioss.There
are presently Z/ connections)In use. This will be the73 11 section.
0 I am the manager of this system.This connection will be to upgrade or Menge the use of an existing
connection on this system(Le.:recreational to full tine).Please indicate on the following line the nature of
this Changs:
This water system is able and willing to provide water to this(these)connectlon(s)without exceeding the
limits of the water system or any limits set by state and tonal reguletlon.f
Print Name of Water System Manager ..A yd t . 1. k`a'phone �V 604 z? G
Signature of Water System Manager ��ir'w"•" /" Date 7/// LMAC
This form may be scanned and available for public view at
1•HI Format Nelms Mier Revised 4,771021
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://gis.co.mason.wa.us/planning 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 adequate supply of
water indefinitely in the future, or guarantee compliance with all applicable WDOE water re ource regulations.
Recommended approval indicates requirements of Sanitary Code, Title 6, Chapter 6.68. urination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements • :relb
hapter
36.70A RCW.
' Unsatisfactory Determination: ^'' ®
Applicants water supply does not appear adequate to meet the needs of its intend use for tl'I�elidv3g
reason(s). SONco,N 2023
0NME
Reviewer's Signatures: D qNT4 ,
fi r
777 ?)
77
,
Environ. Health: Date U
This form may be scanned and available for public view at www.co.mason.wa.us.
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