HomeMy WebLinkAboutWAT2023-00344 - WAT Application - 10/9/2023 WAT
� ' MASON COUNTY
COMMUNITY SERVICES -j,0Z3'C0
: � Budding,Planning,Environmental Health,Community Health
\tintv'i`��
415 N 6th Street, Bldg 8, Shelton WA 98584, ,�V E D
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360)482-5
FAX(360)427-7787
Application for Determination of Water Adequacy OCT -i 9 2023
615 W. Alder Street
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. G C Nv'HO e At-�AL
Part 1: Applicant/ Parcel Identification HEALTH
Name on Applicant: TODD SMITH Date: 2023.10.09
Mailing Address: 220 US HWY 2, LEAVENWORtPhone: 509.670.3130
Parcel Number: 1 21 05-52-001 1 2
Type of Water System Reason for Application Z
O v
Public/Community Water System (2 or more 0 Building permit w 1,9,3 -O 1 1 a) J
connections) D Division of land:
❑ Individual water source (one connection), # of Parcels? SPL
❑ Well 0 Boundary line adjustment
O Spring/surface water ❑ Other(explain)
❑ Other (explain) 0 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 Public/Community 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: TREASURE ISLAND WATER SYSTEM
Water Facility Inventory (WFI) Number: 89150 8
(write "none"for two-party)
❑ I am the manager of this water system. The water system has been approved for services.
There are presently 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:
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.
Date 2023.10.09
Signature of Water System Manager
This form may be scanned and available for public view at www.co.mason�.wa.us.
J:\EH Forms\Drinking Water Revised
NW
rolipp..-
120---- 3 01)5 L
MASON COUNTY __l-f """.
,r.a.,.vt.Ulss4 t u 10
0
COMMUNITY SERVICESa[.r yMri4147.trrt Mr
pr.+r.wr..r...+ .rw./.
I We vo.00.}pte tot SW
Application for Determination of Water Adequacy
na _
anoiwPerts OaOvareraiancrib,nree aa175. as
ntecton
I Mend
SA *by t> a s amapptella n�. kw mar.
4 ao alli
Part 1: Applicant/Parcel Identification
Nine on fRG‘car'rt ._KWIC flu - .,c am —11:40 -..
Maim Addross 4E3 :1tfo W Or tW,S.'1,1►M Or1y Mom r4 714 24711
Type of Water Syelean Reason for Applicsnon
WNW trysteru 11 OF MY* W imort9 t.ei'ni
COMILt+ms r El O.iroo ut and
i oil Partaet' SPL
CI ► e dM aatu i tore tnmeaaat O 8P/dkY tee Llan rs+M
n OR+er t ^I -- CJ Reptaca e`t ere Ronald tip rasensanam+
d*OW►t,x l trier f New--no
is n neei,mart.area cwe ro owra cartected ,ra t
n tr>we.er,meat tdin Pt+Dst-/.a+tn'Mb'N '
5 ydeM to.
Pen 2: Water Connection Information
CrrC 'dtthesrtctrnapor str''oreneinied,.ate,cwrecssmOusearM+see
Public Water System ,
e T� Itrtt)� (C for No chef
:,a Mcrae d wee,y1r*owl' 41itItE4.�.r�t'1�d
ist
Wow faY r++MQn4Crt(WFIF NOW
. wed AY,3 Nr►v5M Thera
a newton
n yalate veil ater* -•.
r 11 1 arta t7�i 1t'/Ea eel _- - clTert
M�oInan p�." r, .a. CorVi•ter use d an ar*tirra
- I tn",Ina W 4Qer o!tai *Oro TM ccrnr*n toori tot 16 c*,re iaeprtnq kne K mare u
Fyrrtk..cn ena MtAar"<'t 'sereatansl o01tq tee fal/eit) ; ;,,,
".... , MR^8Vt� 7rQ 4M
INS C/WOe
8 tills and> to prbADe Will�t0� a ..... _ _.
TtMs t of tf snn oribi ad bud •"
.. ,. braes Or'Is Melt'sYtbih M e•'y tATtt1$al r•1 FtKf.9LeDara�>•tat art
of WOW Siyiler"Wrrager -�
t�eteia Coy an biped pt F1W5
yrtpint ttinaoeg "/3lt[l 2•/ (•`.,.t' rjeltel�iif%
`,t,4^ yri't Nor __ ---------- - __-.
nix tors ewe be erartrnd end raittable ter public
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 http://gis.co.mason.wa.uslplanninq 14j 1151 116n 220
Water use or limitation recorded N/A= Yes I I
Well Drilled Date
Individual Spring/Surface Water
O 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 only)
(y Satisfactory 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-Determination 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).
Reviewer's Signatures:
Environ. Health: Date
CSD Director: Date