HomeMy WebLinkAboutWAT2024-00138 - WAT Application - 2/15/2024 WAT 2ba�! - (15138
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MASON COUNTY SbetMa,WA99594
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Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made unlit 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 Vicki Youngs Date: 02/15/2024
Mailing Address: 1230 W lakeside Dr. Shelton.WA 98584 Phone: 253-312-2065
Parcel Number: 519015001069
Type of Water System Reason for Application
Ed Public/Community Water System(2 or more 12' Building permit-fj 14 ZW-4-6D333
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springisurface water
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please indicate name
n you have more than one residence,connected of water system below if applicable—no
to this well, check the Public/Communtty 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: Mason County Lost Lake
Water Facility Inventory(WR)Number: 463001 (write"none"for two-party)
d 1 am the manager of this water system.The water system has been approved for 93 services.There
are presently 85 connection(s)in use. This will be the connection
Connec ton IS existing
❑ 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.
Print Name of Water System Manager ,M/elissai Cox on behalf of NWS Phone 360A76-0958 ext.109
Signature of Water System Manager. // fYliill � V .behalf behalf of NWs Date 02/15=24
This form may be scanned and available for public view at www.co.mason.wa.0
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Individual Water Well -
❑ Water well report(attached to application). Depth fl.
❑ 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 draw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Imrentay Area(WRIA)
Development within which WRIA htto://ais.co.mason.wa.us/olannino 14115_16_22_
Water use or limitation recorded................................... WA_X_Yes_
Well Drilled _..._...._..---......................................... Date
Individual SpringlSurface 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; 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)
1y( Satisfactory Determination:
/- This determination does not address adequacy of he dis button system,guarantee an adequate s ply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resour M.
Recommended appmval indirates requirements of Sanitary Code,Tdle 6,Chapter 6.68.040-Deters
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. C a
36 70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for t�jpllowing 03 �j
reason(s) T u
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Reviewer's Signatures:
Ertviron. Health: Date
NFq n
This form Ming be scanned and available fair public view at www.m.mason.wa.us.
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