HomeMy WebLinkAboutWAT2023-00355 - WAT Application - 4/25/2023 WAT oJOA
415 N.6°Street
MASON COUNTY Shelton,WA 99584
0 COMMUNITY SERVICES Shelton:360427-9670,&t.400
Belfith,360-2754467,Ext.400
azurers,.,�sr mw.(wxpco mwytxna, Ehni 36P482-5269.Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part i 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: ApplicanU Parcel Identification
Name on Applicant: Sam Marti,Agent for Lenner nonhwes6 In. Date: 4a5la)23
Malling Address: 3M5560,Ave S.Unit 143,Fedeml Way,WA.98003 Phone: R5312541322
Parcel Number: 1232831-00009 •Fo F,m, ,,a
Type of Water System Reason for
2Application
® Public/Community Water System(2 or more ® Building permit f�id�ba3 — d WE35
connections) ❑ Division of land:
❑ Individual water source (one connection), p 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 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: &ZF*,e "JA-wx &JM'Cr- *1
Water Facility Inventory(WFI)Number: ossa
(write"none•for two-party)
❑ I am Ue manager of this water system.The water system has been approved for(,r 3 services.
There are presently ➢q_< connection(s)in use.This will be the 0_connectlon.
❑ 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 wit to provide water to this(these)connection(s)without exceeding
the limits of the water system or any li s set by s and local regulation.
Signature of Water System Manager Date 5" r
This form Ill be sunned and available for public view at www.co.mason.wa.us.
1:TH Forms\Drinking Water Revised 4/44018
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gibm 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 lest,
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 http9/0's co mason wa uslpla and 14_15_16_22_
Water use or limitation recorded................................... NIA Yes_
WellDrilled ............................................................... Dale
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)
�9J Satisfactory Determination:
IThis 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-Deteminatlon of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
U Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of Its intended use for the following
masan(s).
Reviewer's Signatures: � ,(
Enron. Health: D' ✓�l 1 Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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