HomeMy WebLinkAboutWAT2023-00262 - WAT Application - 8/28/2023 WAT OAa ) ce a�a
MASON COUNTY ShelM WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair.360-2754467,Ext.400
aad,, Elmo: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 Identification
Name on Applicant: Pioneer Builders, Inc. Date: 8/28/23
Mailing Address: PO Box 1o94, Port Orchard,WA Phone: 3603403319
Parcel Number: 12218-50-00006
Type of Water System Reason for Application
M PublidCommunity Water System (2 or more 29 Building permit 61QA6A �• QI i"I I
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 this well, check the PublidCommunity 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: a. p"
Water Facility Inventory(WFI)Number: (write"none"for two-party) J
I am the manager_ or this water system.The water system has begn approved for--1 ("✓services.There
are presently U/y connection(s)in use.This will be the y/fin 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(Le.: 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. i� 1`,
Print Name of Water System Manager .a Phone d��/2—�-24 `7
Signature of Water System Manager ate qTJ- zn�
This form may be scanned and available for public view at www.co.mesen.wa.us.
J: 3 Paine\Unvl'ug Water Reviae44272021
Individual Water Well
❑ Water well report(attached to application). Depth k.
❑ Well capacity Test(attached to application) gipm 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 drew-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 htro://ais.co.mason.wa.uslolannina 14_15_18_22_
Water use or limitation recorded................................... INA 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)
Satisfactory Determination:
his 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 W DOE water resource regulations.
Recommended 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
36.70A RCW.
'I 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:
Environ. Health: Date
This form maybe scanned and available for public view at www.co.mason.wa.us.
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