HomeMy WebLinkAboutWAT2023-00357 - WAT Application - 4/25/2023 WAT �ba.?i - QQ
MASON COUNTY 415 N.6'^Street
Shelton.WA 98584
COMMUNITY SERVICES Shelton:360427-9670.Ext.400
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Elma:360482-5269.Ext.400
Application for Determination of Water Adequacy
Instructions LU+ IL
1. Complete Part 1. No determination can be made until 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 she plan must accompany this application,
Part 1: Applicant/ Parcel Identification
Name on Applicant: Sam Martin,Agent for(sonar HarNweat,Inc Date: 4/25/2023
Melling Address: 339556thAw S.flop LB Fa4 r W WA Ba003 Phone: (253)2941322
Parcel Number: 123a!-61 oo+o Tarin,m,_�,e
Type of Water System Reason for Application
® Public/Community Water System (2 or more ® Building permit QL.+(j�-
connections) ❑ Division of land:
❑ Individual water source(one connection), ff of Parcels'+_ SPL
❑ Well❑ Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please indicate name
ff you have more than one residence connected of water system below if applicable-no
to this weft, check the Public/Communi(y 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
Fof
of water System: &,—i-i-il * A+ 71'ssr.CT ay 1
Facility Inventory(WFI)Number: a6-4!rD
it9"none"fortwo-party)
m the manager of this water system.The water system has been approved for / 0 services.
erearepresently �( connection(s)in use.This will De the 897 connection.
m the manager of this system.This connection will be to upgrade or change the use of an existing
nection on this system (Le.:recreational to full time). Please Indicate on the following line the nature
this change:
This water system is able and wZtoide water to this(these)connection(s)without exceeding
the limits of the water system oret by state d local regulation.
Signature of Water System ManageDale 6" r
This form may be scanned and available for public view at www.co.mason.wa.us"
3:\EH Fmme\prinking Weicr Re, N4R018
Individual Water Well
❑ Water well report(attached to application). Depth r.
❑ Well capacity Test(attached io application) gpm 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 drew-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Invento Area (WRIA)
7De"1opmentwfthlnwhich WRIA http://ois co mason wa us/ol inc 14151822on recorded................................... N/A_Yes.................................................... 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 8D0 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 on/
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 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.
i I Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: Wyl Date
This form may be scanned and available for public view at www.co.mason wa us.
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