HomeMy WebLinkAboutWAT2023-00274 - WAT Application - 10/4/2023 WAT 6ft?�
415 N.6°Sh
MASON COUNTY Sheltoe,WA98584
0" COMMUNITY SERVICES Sheltnv 360,427-9670,Ext 400
Belfair.360-275�67,Ext 400
aurmwrwnMamrnxeMrm.,.�N'x..xx EIma:360482-5269,Ext 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: Applicant/Parcel IdeIdentificationName on Applicant: John L DKIi Date:
Mailing Address: 35U I ?1 IrFCf£ Phone:
Parcel Number: Ut'il WA 9IE69A +yi 1-4-y43-. goo9 *;I,
Type of Water System Reason for Application
PubliclCommunity Water System(2 or more Building permit �,tn 2023-o-1 14�
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
ff you have more than one residence connected of water system below if applicable—no
to this well, check the PubliclCommunity Water signature requiredd))L,��^ `n� v(
System box. - 1)0* mis,, "twty �"� � Sf-��
Part 2: Water Connection Information ry me- Trn gll! {, TFC -y'M.e. /1AVH Af�
1D 0te tnS v? i 'Y
Complete the section appropriate for the type of water connection being evaluated.
Public Water System /l—
Name of Water System: K I.W 4,kar7 j C�Cp 15
Water Facility Inventory(WFI)Number. 0/1993 i (write'none'for two-/party)
I am the manager f this water system.The water system has been pproved for 1 services.There
are presently connection(s)in use.This will be the 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 or any limits set bystate and local regulation.
Print Name of Water System Manager AfieiAf t- X;�l Phone
Signature of Water System Manager Uale
This form maybe scanned an available for public view at www.co.mason.wa.us.
r:u:uF�u;�uoewaz� Revis 7=1
Individual Water Well ,
7st///```Water well report(attached to application). Depth 19(>Q ft.
l(Well capacity Test(attached to application) —6b gpm opd.
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
`t( by a licensed contractor.
�I Satisfactory bacteriological test(attach to application).
�1 Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.w.mason.we.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 on/
"NAatisfactory 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 resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-0etemminabon of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
C�lnReviewer's Signatures:
Environ. Health: "Y I Date
This form may be scanned and available for public view at www.co mason wa us.
Page 2 of2
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