HomeMy WebLinkAboutWAT2024-00094 - WAT Application - 1/27/2024 WAT 2e2 ooa9
415 N.6'Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360 70,Ext.400
Belfaic]fill-275J-2754 467,Ext.400
WWg runnM%Em o- Nai HnIlhCmmm IVHW Elma:360-482-5269,Ext 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Pan:water
fully completed.
2. Complete only the portion of Part 2 applying to the type of connection utilized.
3. Submit completed application,with any required attachmeor review.
4. Ana roved buildin site Ian must accom an this a application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: James Martin Date: 01/27/2024
Mailing Address: 24213 41at Ave E Phone: 253-921-2824
Parcel Number: 42318-50.00081 Division-block-lot: DIVISION 3 LOT 81
Type of Water System Reason for�Application
A Public/Community Water System (2 or more ® Building permit 0161 26 2 4— o09AO
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
If you have more than one residence connected of water system below if applicable—no
to this well, check the Public/Community Wafer 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: LAKE CUSHMAN SYSTEM 3
Water Facility Inventory(WFI)Number: 03528E (write"none"for two-party)
❑ I am the manager of this water system. The water system has been approved for1services.There
are presently conneclion(s)in use.This will be the connection.
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: remove Rv trailer and build 2bdm SFR fuNre fun One residence
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 JESSE MATHEWS Phone 360-877-9668
Signature of Water System Manager-
" ,14�4=.m Date 01/29/2024
This form maybe scanned and available for public view at www co mason wa us.
J:TH Forms\prinking Weter Revised 4R72021
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gPm opd.
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 RIA)
Development within which WRIA http,l/gis.m.mason.wa.us/plannina 14_15_16_22_
Water use or limitation recorded.................... . ........... N/A_Yes_
Well Drilled ............................................................... 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)
Satisfactory Determination:
This 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 WDOE 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:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
resson(s).
cReviewer's Signatures: /
� /��/1 Date I
Environ. Health: �_�
This form may, be scanned and available for public view at www.co.mason.wa.us.
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