HomeMy WebLinkAboutWAT2024-00006 - WAT Application - 4/25/2023 415 N.6^Street
MASON COUNTY Shehon,WA98584
COMMUNITY SERVICES Shelton:360427-9670.Ext.400
Belfiir:360-2754467,Exc 400
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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: Applicant/Parcel Identification
Name on Applicant: Sam Martin,Agent for Lerner Northwest,Inc Date: 4/2512023
Mailing Address: 33465 6th Ave S.unit t-B.Federal Wav WA 98003 Phone: (253)294-1322
Parcel Number: 12326-51-00pes -Fw F„e Hsma
Type of Water System Reason for Application
® Public/Community Water System(2 or more ® Building permit F)L.D';t02�'-00CV
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 Publir/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: g'?Ow-+ ":a c :sne.eer #1
Water Facility Inventory(WFI)Number: 05-- 5V
(write"none"for two-party)
I am the manager of this water system.The water system has been approved for 11/4 3 services.
There are presently Aq 7 connection(s)in use. This will be the -RSA-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 tune). Please indicate on the following line the nature
of this change:
This water system is able and willin to provide water to this(these)connection(s)without exceeding
the limits of the water system o any 1 set by sta and I regulation.
Signature of Water System Manager Date T a �.
This form may be scanned and available for public view at www.co.mason.wa.us.
JtlBH Forms\Drinking Wamr Rcvtwd,IW2018
Individual Water Well
❑ Water well report(attached to application). Depth___ ft.
❑ Well capacity Test(attached to application) Atom 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 tt 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 htto/1gis.co.mason.wa.uslplanning 14_15_16_22_
Water use or limitation recorded................................... WA Yes_
Well Drilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to appricatlon)
❑ Method of disinfection
❑ 1 have reason to believe that this water source can provide at least 6DO 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 W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Detenninaeon of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCVI.
❑ 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: Date'( 7/
This form may be scanned and available for public view at www.comason.wa.us.
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