HomeMy WebLinkAboutWAT2024-00179 - WAT Application - 7/25/2023 WATQ / - OD
415 N.6s St
MASON COUNTY Shelton,WA
COMMUNITY SERVICES Sheltom 360-427-9670,Ext.t.400
400
Bclfair.360-2754467,Ext.400
Wyd:yN M%Erwu,mernd{ WCm:emniry He Fl.:360482-5269,Ext.400
Application for Determination of Water Adequacy
Instructions
11. Complete Part 1. No detem,11ation can be made until Part 1 is tulle competed.
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit completed application,wiN any required attachments for review.
4. An approved building she plan must accom n this a licatlon.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Sam Wrdn,Agent tar Lennar N west,Inc Date: 7QW2023
Mailing Address: 334556fh A a Uni11-a Fad I W WA 980D3 Phone. (2531 294-1322
Parcel Number: s •FrFN Ns#76
Type of Water System Reason for
Application
,,,.,.,,y.�
® Public/Community Water System (2 or more RI Building perrnh p�riv`ti �l fl`'f✓1•
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
#you have more than one residence connected of water system below h applicable-no
to this well, check the PublicVCommunity 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
F
Water System:acility Inventory(WFI)Number.e"none'for two-party)
the manager of this water system.The Water system has been approved forre are presently 786 connections)in use.This Will be the 78 fconnecbon.
the manager of this system.This connection Will be to upgrade or change the use of an existing
connection on this system (Le.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willin to provide water to this(these)connection(s)Without exceeding
the limits of the water system o any Iln i set by state§ loc I regulation.
Signature of Water System Manager
L i Date
This form may be scanned and available for public view at www,c^ mason.wa.us.
Revived 4l4rz018
1:\EB Fams,.onnkin8 Water
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) 91)m_ 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 WRIA htto,lla's co mason wa.usiolanning 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes_
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ W DOE permit(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water source can provide at least 800 gallons per day;andlor
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
�j-Satisfactory Determination:/ guarantee an adequate supply of This determination does not address adequacy of the distribution system,g q pp Y
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 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Unsatisfactory Determination:
Applicanfs water supply does not appear adequate to at the needs of its intended use for the following
reason(s).
�7}-�n a Reviewer's Signatures:
Environ. Health: � _ ' I L� ci' Date
This form may be scanned and available for public view at•• co mason.wa.us. Page 2 of 2