HomeMy WebLinkAboutWAT2023-00237 - WAT Application - 7/20/2023 WAT
415 N.6'Street
MASON COUNTY Shelton,WA 98584
Shelton:360ShcIM Q,Ext.5400
84
COMMUNITY DEVELOPMENT Helfair:360-275.4467,Ext.400
xrmKew me a men,eutdnn.marm,n Elma:360482-5269,Exi.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be:ade until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying the type of water connection utilized.
3. Submit completed application,with any reqd attachments for review.
4. Ana roved buildin site Ian must accom this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Richard Adkins Date: July, 20th 2023
Mailing Address: P.O. Box 86 Oak Creek, Will 53154 Phone: 414-702-4932
Parcel Number: 223324190010
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Id Building pennilbid 2623' 61 OJ 5
connections) ❑ Division of land:
Q Individual water source(one connection), #of Parcels? SPL
SI 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 PublicKommunity 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:
(write"none"for two-party)
❑ 1 am the manager of this water system. The water system has been approved for_services.
There are presently connection(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:
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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason,wa.us.
1\EH Fonns\DriNing Weter Revise)4/42018
Individual Water Well
%I Water well report(attached to application). Depth 148 ft. ' �v _
30 Well capacity Test(attached to application) � opm 9pd.
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.
RI Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http//pis co mason wa.us/planning 14_ 15_Z� 16_22_
Water use or limitation recorded................................... N/A1(_Yes_
Well Drilled ... ................ Dale 6-8-2010
...............................
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 W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-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
reason(s).
Reviewer's Signatures:
Environ. Health: Date
This form may be scanned and available for public view at ynaw co mason wit us.
Page 2 of 2
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