HomeMy WebLinkAboutWAT2023-00320 - WAT Application - 10/10/2023 ' WATT- _
MASON COUNTY
COMMUNITY DEVELOPMENT
415 N 6-Street,Bldg B.Shelton WA 98584.
Shelton:(360)427-9670 ext 400 4 Belfer:(360)2754467 ext 400 S Elms:(360)482-5269 ext 400
FAX(360)427-7787
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: Applicant/ Parcel Identification
Name on Applicant: NICOLAE NUTU Date: 10/10/23
Mailing Address: 60 E ANTHONY RD GRAPEVIEVPhone: 206.890.3383
Parcel Number: 221212002000
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 0 Building permit Bl,b;w3-036-7
connections) ❑ Division of land:
O Individual water source(one connection), #of Parcels? SPL
0 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:
Water Facility Inventory(W FI)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 10/10/23
This form may be scanned and available for public view at www.co.mason.wa.us.
J:F Forms\Drinking Wetcr Rwis 1/25MI8
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Individual Water Well
El Water well report(attached to application). Depth 140
El Well capacity Test(attached to application)40 gpm pd.
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.
El Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto//gis co mason wa uslolanninc 7ILO 15�160 22=
Water use or limitation recorded................................... N/AJZL Yeses
Well Drilled ............................................................... Data 10.5.2008
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 WDOE waterj��eeesource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.r�QQg[erm�Iiyn,ation of
Adequacy for Building Permits are satisfied. Additional Growth Management requireme _ ' \ Chapter
36.70A RCW. O
❑ Unsatisfactory Determination: //��
Applicant's water supply does not appear adequate to meet the needs of its iny���use f6ref�ll�wing
reason(s). ?473
Reviewer's Signatures: ry pJq Nr Nq`
Environ. Health: Date
i zu l /loz3 tip/
CSD Director.
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