HomeMy WebLinkAboutWAT2023-00265 - WAT Application - 3/22/2023 1 . '
415 N.0 SUM
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360- ,Ext.400
Belfvr:3b0-27544672]5-0467,Ent 400
a,Mm w.rnr.,:m,,.n.i e°am c—on Elm:360482-5269,Ext.400
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. An approved building site plan must accompany this application.
Part 1: ApplicanU Parcel Identification
Name on Applicant: ELINORE TUCKER Date: Mar 22, 2023
Mailing Address: 4810 SW 317th Ln B,Federal Way WA 98023 Phone: 253-561-2416
Parcel Number: 42205-51-03007 Division-block-lot: iMEcusH16*1MBLK:3 LOT:7
FLbaheuf 6Rbevt
Type of Water System° °°^ °°^'°°""°»'°" Reason for Application G
J0 Public/Community Water System (2 or more ® Building permit "60 2023•D 1 11 1
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,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: LAKE CUSHMAN SYSTEM 5
Water Facility Inventory (WFI) Number: 035290 (write"none"for two-party)
❑ I am the manager of this water system.The water system has been approved for1A 9ervices. 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: Re.adwal to Full Time
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
I.., A1`F°""` Date Mar 22, 2023
Signature of Water System Manager, -...1.-_m==s«'^
This form may be scanned and available for public view at www co meson we us-
1't6H Forms\prinking Water Revised 4/2]2021
Individual Water Well
❑ Water well report(attached to application). Depth It
❑ Well capacity Test(attached to application) opm gpd.
The well driller often performs well capacity tests at the time the well is constructed. Resuhs from
these teats are noted on the water well report. Results from these teats 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 htto/lgis co mason wa us/olannine 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 win 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 dishibution 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,Titie 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).
r�¢n�y�C/('/,,V,,N' Reviewer's Signatures:
Environ. Health:` ' Date — 1�5��'�
This form may be scanned and available for public view at www.co.nms0n.WO.Us.
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