HomeMy WebLinkAboutWAT2024-00132 - WAT Application - 3/3/2023 WAT Z -Lbl 2
MASON COUNTY
000MMUNITY SERVICES
...a ...,e.�.M.d. C..Wftiiwre
418 N 60 Street,Bldg 8,Shelton WA 98684,
Snatch:(360)427-0570 ext 400 O Belfair. (360)2754407 ere 400 O Erne:(360)482-5269 ext 400
FAX(380)427-7787
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination ran be made until Part 1 Is fully completed.
2. Complete only the,portion of Pan 2 applying to the type of water comection utilized.
3. Submit completed application,with any required atectiments for review.
4. Ana ved buildina aft plan must acconipany this application.
Pert 1: AppllcanV P Mel Idendfleatl rid vk y�C
Name Icam: r 5
rpm H T t,� 6
Malting Address: 8020105th Ave SE Olympia, WA pie, ti7a
Paroet Number. .3"A1.14 Ta 1)QL `i l
Type of Water System /Reason for Applica
19' PuburlCanmunty Water System(2 or more M11 lding permit -bI(A2D T
/
connections) ❑ DMalon of land:
❑ Individual water source(me connection), a of Pareels7_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spnngilaurface water ❑
❑ Other(explain) Other(explain)
❑ Replacement a Remodel(please indicate name
N you have move than we residence connected of water system below if applicable-no
to this wee,, check the PublicCommunky 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: F.r f L a tc
Water Facility Inventory(WFI) Number: L 3 Z4YL4 IN
(wrte'none'for two-party)
IK I am the manager of Pi�wg��1tter system.The water system has been approved for �1 S�servlcas.
There are presently connection(s)in use. This will be the /yp T correction.
❑ 1 am the manager of this system.This connection will be to upgrade of charge 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:
TNs water system is able and willing to provide water to this(these)connections)wtfaut exceeding
tie limb of the water system or any limits set by stale and local regulation.
Signature of water system Manager
This form may,be amnned and svallable for public view at www,co.mason.wa.us.
l TH rorinskI xkina Wsw ltv,e 1r1Y1018
Individual Water Well
❑ Water well mpt z,,(attached to appiicarmn). Depth_ /R
❑ Well capacity Test(aN�'hsd to application) _ _ fg gpd.
The wail driller often perfo mb veil capacgy tests /o time 118 well Is constructed. Results from
these tests are noted on the we!. well rep^ eauNs from these tests witl be accepted. If the water
wail report cannot be located by the .cent or tithe water well report does not have a capecay test,
a well capacity test, which provW tabi.� yion of draw-clown and recovery data, ,at be performed
by a licensed contractor. i
❑ Satisfactory bactayel'ogical test(attach to application-
Water Resource Inventory Area (WRIA)
Development within which WRIA / .n 14E31501t0270
Water use or limitation recorded NIA _Yeg_=
Well Drilled ....................... .................................... Date
Individual SpringlSurface Water
❑ WDOE commit(attact,,leapplistion)
❑ Method of disinfection
❑ I have reason to believe that this:>ater source can pro,-'a at least ROO gallons per day, and/or
Provides water at a rate of 2 gallons, s; minute bar, on the following observations.
Author of Statement Date
Relationship to Applicant
Part 3: Mason_County Community Services Evaluation (SteBuse on/
A! satisfactory Determination:
The determination does not address adequacy of the distribution ayatam,ouaranme an adequate su,Ply er
water irmdefini0-I In the➢tWre,or guarantee compliance with all applicable WDOE water resource ragulasons.
Recarnmended appmval Indicates requirements of SaniW ry Code,This 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may appry. Chapter
36J0A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequafB to meat the needs of es ireegee ago for the looming
mason(s).
� Resl/alwars Signatures: �(Environ. Haab: �1 `vuY t,Yl'u" I Date—i._'ti-'�i---
CSD Director,_ Dora o arz