HomeMy WebLinkAboutWAT Application - 12/28/2022 uy-� � � 6D I20v Nern,�i(n5
WAT
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MASON COUNTY W Shchor4 WA 98534
COMMUNITY SERVICES Shd 360-427-9670,ER.400
Mau..360-2754467,FW.400
deayrgMyrmammnglxrq<ann.nlgxxlN Elmer 3"2-5269,Fat.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 aeproved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Jason Campbell Date: 1 212 8/2 02 2
Mailing Address: 406108th ct8 Tacoma WA 98444 Phone: 253-241.3594
Parcel Number: 321275300167 LAKE LIMERICK 4 TRACT 167
361 E BALBRIGGAN RD
Type of Water System Reason for Application
HI Public/Community Water System(2 or more 10 Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), p 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 PublicXommunity Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water L 1� System{
Name of Water System: �. �- n Ef iC t VJ ak "
Water Facility Inventory(WFI)Number: 4 yh- (write"none"for two-party)
I am the manager of this water system. The water system has been approved for L��services.There
are presently I LULI _connection(s)in use. This will be the IZkL4_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 e'Kir 5 1r `e- Awlen Phone ai_ '�1Z 79 )Sb
Signature of Water System Manager Oj,- w �Ih r7/rs o. _ Date
This forts may be scanned and available for public vies,at w p,"Ithiun.wa.us.
JEll Fw s\Dn ina Watt Revised 4/272921
Individual Water Well
❑ Water well report(attached to application). Depth tt.
❑ Well capacity Test(attached to application) opm 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.
i
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WR A)
Development within which WRIA :// is.co.mason.wa.us/ [arm- 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes_
Well Drilled ............................................................... Date
Individual Spring/Surf ce Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source n provide at least 800 gallons per day; and/or
provides water at a rate of 2 gallons per min a based on the following observations.
Author of Statement Date
- 'Relationship to Applicant
Part 3: Mason Court Comm ni Services Evaluation (staff use onl
ISatisfactory Determl pion:
This determination does n address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the re,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended appro indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Buildi Permits are satisfied. Additional Growth Management requirements may apply. of
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: ulvinDate Z 6
This form may be scanned and available for public view at�",numn.wa.us.
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