HomeMy WebLinkAboutWAT2023-00348 - WAT Application - 12/4/2023 WATT- OD346
415 N.6°Sheet
MASON COUNTY Shelton,WA 99584
COMMUNITY SERVICES Shelma:360427-9670,Ext400
Belfair.360-2754167,at 400
a'a^A°e^^"9r^.•�.,�.�wx.4inca,.,..arw4w El.360482-5269,at 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 ap2noved building site plan must accompany this application.
Part 1: Applicant/Parcel Identification
Name on Applicant:Ted Hultman Date: December 4, 2023
Mailing Address: 2532 Summit Lake Shore Rd NW Phone: 386789-1345
Parcel Number. 32021-56-01038
/ Type of Water System - / Reason for Application
Ed Public/Community Water System(2 or more try Building permit 6LD 9*'3—OI46QP
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdng/sudace water
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please indicate name
)/you have more than one residence connected of water system below 8 applicable—no
to this well, check the Public/Communiry 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: Shorecrest Estates Water Company
Water Facility Inventory(WFI)Number: 78602-1 (write'none'for two-parry)
❑ lam the manager of this water system.The water system has been approved for_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: Existing Connection - Building Permit
This water system is able and willing to provide water to this(these)connections)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Knstie Hutchinspn Phone 36042ee773
Signature of Water System Manager. Date 12/42023
This form may be scanned and available for public view at www.co.mason.wa.us.
J\EB Finass Drinking Waxr Revisal 427=i
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) opm gpd.
The well driller often performs well capacity tests at the lime 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
byle-11censed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WR1A
Development within which WRIA hfto;//Qis.co.mason.wa.us/planning 14_15_16_22_
Water use or limitation recorded............................. ..... N/A Yes
Well Drilled ...........................................:................... Dale
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 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)
10�10Satisfactory Determination:
This determinatlon does not address adequacy of the distribution system,guarantee an adequate supply of
water indefnitaly in the fuWm,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,True 6,Chapter 6.66 040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A ROW.
❑ Unsatisfactory Determlmalion:
Appiicanfs water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Elwiron. Health: % rie' ' Date Z 'Z
This form may be scanne and available for public view at www.co.mason.wam .
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