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Home My WebLink AboutWAT2023-00356 - WAT Application - 12/11/2023 ENVIRONMENTAL - --- --- -- -- -----kIE��T-ki-- - --_ �L1�C� 1�Q93 MASON COUNTY RECEIVED COMMUNITY SERVICES DEC 11 2023 lkili PWni%EmlmnmeMel Hmith,C munhyt Fffi 475 N 6-SGeat,BItl9 8,Shelton WA 98584, 615 W. Alder Street Shehon:(360)427-9670 ext 400 O Belmir.(360)275-4467 ext 400 e Elma:(360)4825269 ext 400 FAX (360)427-7787 Application for Determination of Adequacy Instructions 4. P 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 system utilized. SUbmlt cam feted application,with attachments to the health departmentfor review. Part 1: Applicant/ Parcel Identification ii dWnzx ' 044��'-bro�-� Name on Applicant:naioLiq Date: I =l Mailing Address: � Zda 11_lte f Ei Phone: -Q Parcel Number:: 32021 _AA - Q2Q$7 Type of Water System Reason for Application n7� h11(j 1g Public(Communhy Water System(2 or more Building permit connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels?_ SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement(please indicate name of water If you have more than one residence connected system below if applicable-no signature to this well, check the PubkclCommunity Wafer required) System box. APPROVED Part 2: Water System Information DEC 2023 2 7Complete the section appropriate for the type of water system being evaluated: MASON CCUNIY6HVIRONVENHNENiAL HEALTH Public Water System RET Name of Water System:y%yimni Water Facility Inventory(WFI)Number: 79We20 -I (write"none" r two-party) ❑ 1 am the manager of this water system.The water system has been approved for services. There are presently connection(&)in use.This will be the connection. 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.:fr�ecrep onal to full time). Please indicate on the fol"ng line the nature of this change: '�wttr�irn KlIe1J This water system is able and illing 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 n Phone 3 d Signature of Water System Manager IDate J1EH Fumu\Dnrking Wekr ]u,i 3119n021 F.,I oft This form may be scanned and ar"llable for public view,on the Masan County,Web site. Individual Water Well ❑ Water well report(attached to application). Depth ft ❑ Well capacity Test(attached to application) apm gpd. The well driller often performs well cspeolly 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. it the water welt report cannot be located by the applicant or ti the water well report does not have a capacity test, a well capacity test,which provides stablgmtlon of draw-down and recovery data, must be performed by a licensed contractor.. ❑ Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA Devalopmentwitliln which WRIAhtte,/IaiscomosonwsusAriennina 14_15_i6_22_ Water use or limitation recorded................................... N1IA _Yes_ WellDrilled............................................................... Date Individual Spring/Surface Water I ❑ WDOE pemdt(attach to application) ❑ Method of disinfection ❑ I 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 I Author of Statement t Data -.-- Relationship to Applicant Part 9: Mason County('.ommunity Services Evaluation (Staff uae Only} 1 ❑ Satisfactory Determination: This determination does not address adequacy of the d-stdbtirnn system,guarantee an adequate supply of water indefinitely in the fisure,a guareruee compliance Wth ell applicable WDOE water resource regulations. Recommended approval indicates requiramerde of Sanitary Code,Tire 6,Chapter 6.68.040-Determination of Adequacy forSugding perils are satisfied. Additional Growth MaragemaA requirements may apply. Chapter 86.70A RCW. . D Unsatisfactory Determination: Applicant's wafer supply does ndappear adequate to meet ft needs of Its Intended use brine follovdng mason(s). ' Reviewer's Signatures: Envvon. Health: Date CSD Director; Date 3af]