HomeMy WebLinkAboutWAT2024-00171 - WAT Application - 3/15/2024 WAT ,t -� 1
MASON COUNTY
COMMUNITY DEVELOPMENT
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415 N 6^Street,Bldg 8,Shelton WA 98584.
Shelton:(360)427-9670 elm 400 4 Belralr(360)2754467 em 400 O Elms:(360)482-5269 ext 400
FAX(360)427-7787
^'Q Application for Determination of Water Adequacy
v Instructions
t. Complete Part 1. No determination can be made unfit 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 Identiffication
Name on Applicant: MOLLY CLARK Date: 03-15-2024
Mailing Address: PO BOX 189 SHELTON, WA Phone: 360-463-8343
Parcel Number. 42002-00-62000 (PARTIAL)
Type of Water System Reason for
�_Application
RIPublic(Community Water System (2 or mom � /n6
Building permit C M 2D2,d ' 000 t t5
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL_
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
O Other(explain)NTNC-GrouDA
❑ Replacement or Remodel (please indicate name
If you have more than one residence connected of water system below 8 applicable—no
to this welt, check the Pubba Community 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: Port of Shelton Sanderson Field
Water Facility Inventory(WFI)Number. 688353
(write'none for two-party)
0 1 am the manager of this water system. The water system has been approved for 398 services.
There are presently 39 cenneution(s)in use. This will be the 40 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 spy state and local regulation.
Signature of Water System Manager _Date 03-15-2024
This form may be scanned and available for public view at www.co.mason.wa.us.
1:01 F. Dnnkinr Wafer Re ,i Ir15a
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpro 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 W RIA htho 1/gis.m.mason.wa.us/planning 140 1 5=16=22=
Water use or limitation recorded................................... N/Aj=[_Yeses
WellDrilled ............................................................... Date
Individual Spring/Surface 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)
LJ atisfactory Determination:
is determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Unsatisfactory Determination:
Applicant's water supply does not appear adequate to most the needs of its intended use for the following
reason(s).
rn Reviewer's Signatures:
Environ. Health: 1�T� Date
CSD Director:
Date 2°f 2