HomeMy WebLinkAboutWAT2024-00088 - WAT Application - 11/7/2023 FAT_�-oa�} ooze
415 N.6'a street
MASON COUNTY Shelton,WA t.584
400
COMMUNITY SERVICES Beltaa:360-2754467.EcL 400
Belfau:360-275-0467.Ext.400
sari"y w.,�aE..ummw4HWConnnlhaxlA Elma:360492-5269,Ext.40D
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. Ana roved buildingsite Ian must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant:L�mn Fatnls,Agent for Lennar Nortlmrest.Inc Date: 1117123
Mailing Address: 334s56thA B UM 1-8 Fede lWav WA.%W3 Phone: 1253)308-0265
Parcal Number: 2326 mono 2a2 moan F asx2s
Type of Water System Reason for Application
55 Public/Community Water System(2 or mom 0 Building permit 5aac)A4—OOI99
connections) ❑ Division of lard:
❑ Individual water source(one connection), #of Pamels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
ff you have more than one residence connected of water system below if applicable—no
to this Well, check the PubliatCommuniry 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: Q.�A'_ " 16y �i�rcjo'
Water Facility Inventory(WFI)Number: 406
(write"none"for two-party) '',
I am the manager of this water system.The water system has been approved forservices.
There are presently A/& wrinection(s)in use.This will be the Sri/7 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)connections)wilhout exceeding
the limits of the water system or an mits set by state nd local regulation.
Signature of Water System Manager Data f/ /$
This form may be scanned and available for public view at www co.mason.wa.us.
Revived 442018
1^EH Farma\thinking Warn
Individual Water Well
❑ Water well report(attached to application). Depth tt•
❑ 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 Invento Area (WRIA
Development within which WRIA http//qis.co.mqson.wa.us/plannln9 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 80D 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 on/
7Applimnts
ctory Determination:
ermination does not address adequacy of the distribution system,guarantee an adequate supply of
definitely in the future,or guarantee compliance with all applicable W DOE water resource regulations.
ended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Deteortination of
cy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
RCW.
isfactory Determination:
nts water supply does not appear adequate to meet the needs of its intended use for the following
s).
Reviewer's Signatures: ( cf
Environ. Health: Date IZ I
This form may be scanned a available for public view at www rb mason•wa•as, N,z ore