HomeMy WebLinkAboutWAT2023-00285 - WAT Application - 5/15/2023 WAT 2A23 - Cb28S
415 N.6^Street
MASON COUNTY Shelren,WA 98584
COMMUNITY SERVICES Shelton:360.427-9670,at.400
Belfair.360-2754467.at.400
lie+arlm.�arn,mma.�wx.rlavcan.�..lyxwa Elms:360482-5269,at.400
Application for Determination of Water Adequacy
Instructions
i. 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 Date: 5115123
Mailing Address:
33465 eth Ave S,unit 141 Federe Plane:
l Way.WA 98003 253-294-1322
Parcel Number: 12328-51-00018 /s/ Nt Rrc�a 1/7Gess:nJc yl51ro0/e
Type of Water System Reason for Application
® Public/Community Water System (2 or more ® Building permit i 126Z 3 61 aa'S
connections) ❑ Division of land:
❑ Individual water spume(one connection), #of Pdreelsv 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 PubficlCommunify Wafer 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: Bc./�at rlr 406 2�k g4ir c-f
Water Facility Inventory(WFI) Number: d S SS-0 (write"none'for two-parry)
/-6 1 am the manager of this water system.The water system has been approved for//Q,Lsetvices.There
are presently 9/2 connection(s)in use.This will be the 4/3 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 by state and local regulation.
Print Name of Water System Manag le A 1,,46 Phone .S�lO•��S••3dtl8
Signature of Water System Manager Date . A /R[_Z3
This form may be scanned and available for public view at www,co.mason.wa.gs.
k: fl Fomv\Ddnkina Water Revised 4R7/2021
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity 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 hfto://gis.co.mason.wa.us/olanning 14_15_16_22_
Water use or limitation recorded................................... NIA_Yes_ !i
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 only)
JT Satisfactory Determination:
IThis 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 reguladons.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-Daterminatbn of
Adequacy for Building Penults 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).
Reviewer's Signatures: 1 7
Environ. Health: ° I' f Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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