HomeMy WebLinkAboutWAT2023-00266 - WAT Application - 10/24/2023 RECEIVED �a
OCT 2 4 2023 OCT 3 12023
615 W. Alder Stre RECEIVED WAT a(L
MASON COUNTY 415 N.6n Stmxt
QD COMMLiNTTy SERVICES Shelly,WA 99594
Shelly:360A27-Wil Ent.400
a,teyw„agrow�m.wi a.M rpx,y, aelfal ..360-2754467,Ext 400
Elmo:360492-5269,Ext.4W
Application for Determination of Water Adequacy
Instructions
1 Complete Part 1. No determination can be made until Part 1 is fully comoleted
2. Complete only the portion of Part 2 applying to the type of water connection util¢ed.
3. Submit completed application,With any required attachments for review.
4. Ana roved building site Plan mustaccompany this applicaix,
Part 1: Applicant/ Parcel Identification
Name on Applicant: Came&Timothy Blanchard Date: 1D/24/23
Mailing Address: 1170 E. Daniels Rd.Shelton WA 98584 Phone: 360-402-8825
Parcel Number: 32010-51-03014
Type of Water System Reason for Application
B Publideommuntty Water System(2 or more B Building O 118�
connections) g permit Zia 2023-
❑ Individual Water source(one connection), ❑ Division of land:
❑ Well N of ParcelS7_ SPL
❑ Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
lyyoa have yam than one residence connected ❑ Replacement or Remodel(please indicate name
to this aeM, check the Pubikc Community Water of water system below If applicable-no
System box. signature required)
Part 2: Water Connection Information
Complete the section appropriate for the type of Water connection being evaluated:
Public Water System
Name of Water System: Cedar Grove
Water Facility Inventory(WFI)Number: 11914K
(write"none*for two-party)
B 1 am the manager of this water system.The water system has been approved for 88
are presently 69 connection(s)in use.This will be the 5s pp services.]Themconnection.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an existi
connection on this system(i.e.: recreational to full time). Please indicate on the following line the n
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.
Print Name of Water System Manager Shawn O'Dell Phone 253-85 -40§0
Signature of Water System Manager Date �, t OL}
This form may be scanned and available for public view at www,mmason
3:1EH P.m %Drinking Waw
devil 442742021
Individual Water Well
❑ Water well report(attached to application). Depth tt,
❑ Well capacity Test(attached to application) gpm clod.
The well driller open 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 oannot 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 hdo-/lais.co.moson.wa.us/planninu 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes—
Well Drilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(affach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source can provide at least 600 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 appliceble 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 RCK
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet fhe needs of its intended use for the following
reason(a).
Reviewer's Signatures:
Environ. Health: )/ p ry I Date
This form may M conned a d a-liable for public view at lydan i.w.fsas;on.wa.us.
Peaelafl