HomeMy WebLinkAboutWAT2023-00283 - WAT Application - 5/15/2023 L.o+ 141
WAT OOAi��1
415 N.6'"Street
MASON COUNTY Shelta WA98384
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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 aocompany this application.
Part 1: Applicant/Parcel Identification
Name on Applicant: Sam Martin,Agent for Lerner NorthwestDate. 5115123
Mailing Address:
33455 SM Ave S.Ne 1-13 Phone:
FOS*Way,WA 9800J 253-294.1322
Parcel Number 12328-51-00041 ZZ/ N58cf{erx S ,; 'soa *Sy 004/l
Type of Water System Reason for Application
* Public/Community Water System (2 or more IN Building permit$ld 20123.0I AAA
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
If you have more than one residence connected of water system below if applicable-no
to thfs 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: 261A&- &)44. ✓attc'/ra-,+ *1
yyyW���ater Facility Inventory(WFI)Number: 053S (write"none"for two-parry)
p I am the manager of this water system.The water system has been approved for 03 services.There
are presently 11b connection(s)in use.This will be the 9 j/ 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 Manager a /�.-.6 Phone Ad-17S-3608
Signature of Water System Manager Date 4 Ze
This form may be scanned and available for public view at www.=MaSt n.wa.us.
J:EH Fomsa Dnnkin8 Water Revised 4i2711@ I
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 hltw//ais.co.mason.wa.us/planning 14_15_16_22_
Water use or limitation recorded................................... WA 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;andfor
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)
,,LL111 Satisfactory Determinatlow
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.
mmended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
3670A RCW,
Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meal Me needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: 1 y' I Date 13'2.
This form may be sunned and available for public view at www.co.mason-wa.us.
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