HomeMy WebLinkAboutWAT2023-00352 - WAT Application - 5/15/2023 WAT aG 'I Q��i52
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MASON COUNTY -4279a,0, t.400
COMMUNITY SERVICES Shelton:360-22i-4467,Ext.400
BElm:360. 82-5269.Ext.400
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Application for Determination of Water Adequacy
Instructions
�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. Ana raved buildingsite Ian must accompany this a lication.
Part 1: Applicantl Parcel Identification
Name on Applicant: Sam Martin,Agent for Lerner NorthwestDate: 5115/23
33455 9th Ave S,Unit 141 Factori al Way,WA 96003 Phone: 253-294-1322
Mailing Address: �.�,,^
Parcel Number: 12328-51-0002 i11 NE �I"7-'—r cmirt
Type of Water System Reason for Application
IN Public/Community Water System(2ormom ® Building permit 16L12OZ3 -01LI-I
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdng/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
N you have more than one residence connected of water system below if applicable—no
to this well,check the PubliclCommunity 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: -
Water Facility Inventory(WFI)Number: DS3S00 (write'none'for two-party)
I am the manager of this water system.The water system has been approved for 14 05 services.There
are presently -7 S connection(s)In use.This will be the ' 4Q 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(Le.: 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)wrinection(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager �6 Phone �ildJ -1�S'3OU4/
Signature of Water System Manager Date S' S 2 A
This form may be scanned and available for public view at wanw.co.mason.wa.us.
Revim 4/27/2021
1\EH Forms\DririkinH water
Individual Water Well
❑ Water well report(attached to application). Depth It.
❑ 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 (WRIA)
Development within which WRIA http Ygis.co.masonma.us/glanning 14_15_16_22_
Water use or limitation recorded......................... .... N/A_Yes_
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 Dale
Relationship to Applicant
Part 3: Mason County Corringuinity 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.
I_I Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its Intended use for the following
reason(s).
Reviewer's Signatures:
Date
Environ. Health: YWl Z I�
This form may be scanned and available for public view at garvinfif.co.mason.wa.us. Page 2 of 2