HomeMy WebLinkAboutWAT2024-00018 - WAT Application - 6/16/2023 WAT �- _
415 N.66 St=t
MASON COUNTY SlAton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
aclftir:3W.2754 7,Ext,400
x..ln Ebric 360482-5269,E.I.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.
4. An approved building site plan must accompany this application.
Part 1: Applicantl Parcel Identification
Name on Applicant: Sam Macon,Agen(W Lennw Northwest,Inc Date: W16J2023
Mailing Address: 334556N Ave S.unit l-a Fe6eral Way,WA gew3 Phone: (253)21W1322
Parcel Number. 12329-51.OM2 •Fer Future Ns H2
Type of Water System Reason for Application �/
la Public/Community Water System (2 or more ® Building permit-Bu)')Lo -Ocov
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springisurface 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 PublicXommunify Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
�i, Public Water System
Name of Water System:
Water Facility Inventory(WFI)Number: n5.350
(write"none"for two-party)
I am the manager of this water system.The water system has been approved for, t�,Q.21-services.
There are presently 75-7 connection(s)in use.This will be the75A connection.
❑ 1 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 o an its set by stat and local regulation.
Signature of Water System Manager Date Ia )?
This forat may be scanned and available for public view at www.co.mason.wa.us.
II
JAEN fomu.Drinkio8 Wa1v Revised 4/4/2g18
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://ais.m.mason.wa.us/planning 14 15 16 22
Water use or limitation recorded................................... N/A Yes
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ W DOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source can provide at least 800 gallons per day;andlor
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Daft
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 W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.66.040-Daterminadon of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
'....I Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: `f P l Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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