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HomeMy WebLinkAboutWAT2023-00158 - WAT Application - 4/4/2023 WAT ,21)9,;�_- fl0159� 415 N.6ie Strat MASON COUNTY Shelton WA 98594 0 COMMUNITY SERVICES Shelton:360-2754467.ExL 400 I3clfeir 360.275d967,I:xl 400 ryyyrw.n9rna�.wnl�a�camm�mrwwu Elms:560 482.5269.Hxt 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 buildinq site plan must accompany this application. Part 1: Applicant/ Parcel Identification Name on Applicant: David Rail Date 04/04/2023 Mailing Address: 150 NE Evergreen Dr. Phone: 1-206-405-0717 Parcel Number: 22205-50-00015 Type of Water System Reason for Application /' %I Public/Community Water System(2 or more ID Building permit�60.20A-- - ooa511 connections) ❑ Division of land: ❑ Individual water source(one connection), #of Pamela? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name If you hem more then one residence connected of water system below if applicable—no to this well, check the PubliclCommunity 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:Tahuya River Valley Water District Water Facility Inventory (WFI) Number: 87115N (write'none"for two-party) I am the manager f t is water system.The water system has n a proved for�{eservices. There am ;resently connection(s) 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.: recreational to full time). Please indicate on the following line the nature of this change: Ho ,n.pw axauns meter 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 by state and local regulation. Print Name of Water System Manager Drew Noble,H2O Management Services Phone 360469-6189 Signature of Water System Manager li+e=�� �"P�"��� Date V ZOZ This form may be scanned and available for public view at 1NW W co masert.wa,us, J:\F.H Fame\Thinking Wetcr Reviud 4=021 Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well rapacity 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 hltp//gis.co.mason.wa.usiplanning 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 ❑ 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 ly) Satisfactory Determination: This determination does not address adequacy of the distnbution system,guarantee an AeZaje y of water indefinitely in the future,or guarantee compliance with all applicable WDOE water resour Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.6QpAq Delermm m. Adequacy for Building Permits are satisfied. Additional Growth Me..._m—owN Nry m(b`p . Chap 36.70A RCW. ��((// ❑ Unsatisfactory Determination: ENU/g0/yu� Applicant's water supply does not appear adequate to meet the needs of its intended us�tha'7DY{y�ir76,_ reason(s). '�Cq( Reviewer's Signatures: Environ. Health: Date O This form may be scanned and available for public view at www co mason wa us. �sr z orz