HomeMy WebLinkAboutWAT2023-00154 - WAT Application - 5/2/2023 MASON COUNTY
COMMUNITY SERVICES
boil Jin%Plain%Erwlmnmeotal Healti,Community HealUt
415 N fiei Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 e t 400 0 Belfalr:(360)275-4467 ext 400 0 Elms:(360)482-5269 exi 400
FAX (360)427-7787
Application for Determination of 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 system utilized.
3. Submit com leted application,with attachments to the health department for review.
Part 1: Applicant/ Parcel Identification I
Name on Applicant 14 Date: 5_4123
Mailing Address: ( � Phone:: I
Parcel umber:: ?(q0y(, y
Type of Water System Reason for Application7c,z
tL Public/Community Water System(2 or more 19 Building permit $Ird zV73.06 7 Il
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surfacewater ❑ Other(explain)
❑ Other(explain) ❑ Replacement(please indicate name of water
If you have more than one residence connected system below if applicable-no signature
to this well, check the Pubflc/CommunHy,Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
r Public Water System
Name of Water System: rN 'L A r V_,0
I
Water Facility Inventory(WFI) Number �'T I j
(write'none*for two-party)
I am the manager of this water system. The water system has been approved for services.
There are presently u AA connection(s)in use.This will be th^'l-]i5—JF neonnection.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(is.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willing to pro'I water to this (these)connection(s)without exceeding
the limits of the water system or an lim s Vt y state and local regulation.
Signature of Water System Manager Date ✓C Z
J.WH Foma\Drinking Weler Revised 1211115
Pugs I oP2
This form may be scanned and available for public view on the Mason County Web site.
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Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm gpd.
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 htt0//qis.co.mason.wa.us/vIanmnQ 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes__
Well Drilled ............................................................... 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 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 upply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water rea r a6ons.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Deter f
Adequacy for Building Permits are satisfied. Additional Growth Management re;uSements may apply. tar
36.70A RCW. �s99 ^I
❑ Unsatisfactory Determination: NC�NN e719
Applicants water supply does not appear adequate to meet the needs of its intended use r folio
reason(s). `ygdNNFNn�
Reviewers Signatures: ��� NFg6P
Environ. Health: Date
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This form may be scanned and available for public view at www co mason wa us.
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