HomeMy WebLinkAboutWAT2024-00089 - WAT Application - 3/2/2023 WAT
415 MASON COUNTY UM A98594
Sheh96 WA98584
COMMUNITY SERVICES Shelton:360-2754467,Ext.400
Belfeir.360.275�4467,Ext.400
Burd.q Pbmx°r ".rvd xrincam.nnyxxlM Elmer 360482-5269,Eat 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully wmoleted
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: Nyasa Lemay Date: 03/02/2023
Mailing Address: _ 282 W. Little Nahwatzel Dr. Phone: 206-459-4492
Parcel Number: 52009-75-00100
Type of Water System Reason for Application
Ld Public/Community Water System(2 or more G( Building permit b ld U24,601%
connections) ❑ Division of land:
❑ Individual water source(one connection), g of Parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spnng/surface water El Other Other p Other(explain) (explain)
❑ Replacement or Remodel(please indicate name
ff you have more than one residence connected of water system below lf applicable—no
to this well, check the PubholCommun/)(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
7Facility
ter System: Little Nahwa I
ty Inventory(WFI) Number: 06466J (write"none'for two-party)
manager of this water system. The water system has been approved for 6services. There
ently 4 connection(s)in use.This will be the _connection.
manager of this system. This connection will be to upgrade or change the use of an existing
ion on this system(i.e.: recreational to full time). Please indicate on the following line the nature of
nge:
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 stale and local regulation.
Print Name of Water System Manager Melissa Cox on behalf of NWS Phone 360-87"958 ext. 104
Signature of Water System Manager %' -V Date 03/0212023
_11This form may be scanned and available for publk view at www.00.masonma.us.
1:1EH Fo mA lkW i%Water rt�4mrzo2r
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 f/ is co mason wa uslolannina 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes_
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ 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 Data
Relationship to Applicant
Part 3: Mason County Community Services Evaluation staff use on/
P Satisfactory Determination:
This deternination 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 require may apply. Chapter
36.70A RCW. 'f /p�y�
❑ Unsatisfactory Determination: 1,i�
Applicants water supply does not appear adequate to meet the needs of its intended usq_��a fallowing C
resson(s). M
l�Asou o) 81
Reviewer's Signatures: B8 fNVI", �+Q�,M
Environ. Health: , Date
This form may be sounded and available for public view at www co mason.wa.us.
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