HomeMy WebLinkAboutWAT2024-00145 - WAT Application - 3/12/2024 �ol k� e-�Ck wAT
MASON COUNTY -I
COMMUNITY DEVELOPMENT I M 4 1
P—ItR lsmmeuM Axldh, Nanning O I— 1 1
415 N 6s Street,Bldg 8,Shelton WA 98584,
Shelton:(300)427-9670 ext 400 P Belfaic(360)275-4467 ext 400 0 Elms:1360)482.5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy Q
Instructions ` rD QrN 1`.(P-55 13 t r- A cC Tc
1. Complete Part 1. No cistennination can be made until,Part 1'is fully Completed, - - -
2. Complete only the portion of Part 2 applying to the type ofwater connection utilized.
3. Submit completed application,with any required attachments for review.
4. An sop roved bulldln6 siteplan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: M4I Date: 3IIy/2j14
Mailing Address: 59�1 ��ntieT P_,pl Phone:
Number:
Parcel �a1977-6-0 -he)i1�
Type of Water System Reason for Application
aiil`Publlc/Community Water System(2 or more JK Building pem h&,bay -oo34�
connections) ❑ Division of land:
❑ Individual water source(one connection), - #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdng/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: LQ
''
Water Facility Inventory(WFI)Number: 441 sbT
�dt (write"none'for two-party)
rtl�I am the manager of this water system.The water system has been approve for l �ewices.
There are presently J V�`t connection(s)In use.This will be the connection.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(Le.: 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
/�lim�its set bby�s�tate and local regulation.
Signature of Water System Manage r-Y/L(!A /GLe' 'hu-1 Date
This form maybe scanned and available for public view atwww.co.mason.wa.us.
Pi Pomsl Unnking Waw Revised II25Q018
i�
Individual Water Well
❑ Water well report(attached to application), Depth ft.
❑ Well capacity Test(attached to application) apm 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 he 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-dawn and recovery data,must be performed
by a licensed contractor.
4 Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hltwUnis,co.mason.wa.us/olannina 14=]15E=16=22E=l
Water use or limitation recorded................................... N/AJZL Yes Q
Well Drilled............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I 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 Data
Relationship to Applicant
Part S: Mason County Community Services Evaluation staff use only
Satisfactory Determination:
This delertnNation does not address adequacy of the OlaMbuaon system guarantee an adequate e y of
walerintleli itely In the future,of guarantee compliance with all applicable WDOE water resource
Recommended approval Indicates requirements of Sanitary Code,Title 6 Chapter 8.8a 040-D—e Is Anno
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Ch
9S70A RCW.
❑ linsattsfactory Determination: *4S,8�{y"�po�sMt .Qy
Applkxnrs water supply does not appear adequate to meet the needs of its Intended use for tIS6�Ililaxing 24 Fo
reeson(s). _ 7p-
NO
Reviewer's Signatures: `✓q N'�F
_ f !
Environ. Health:T� Date N��IF'
CSD Director: Date :afs