HomeMy WebLinkAboutWAT2024-00189 - WAT Application - 4/1/2024 MASON COUNTY WA
COMMUNITY DEVELOPMENT
915 r!5^Suev1.BMg 6,Shelton WA 4a59e.
9haaal (�)427-9670 ad Mo •+ Bel 51 leg e00 4 Yena (3110)eat a269 and e00
FAX(JBU)4]
Application for Determination of Water Adequacy
Instructions an.� --
1. complete Part 1. Na dalerminMan c be made anti Pan I Is INI
2, cgmptt only the won of Pan 2 eFF pn9 M the type of water connection utlNzed.
3. $utnIt cpmDeled adipkailon,wdh any required attachments for tavrew.
roved bulldm to pl t accompa Y this at ion
4. An _
Part 1: Applicant/Parcel Wntificatione.✓
Name on Apphranl �N4 Mud 4sc y} t3.rm.} Dal. .Cl4j!� 171L`I
Matting Address. 4434 A 1—Phort'. 3Lc yro 00"1 V'5j&' r
Pastel Number ' l r"sA,e✓A , W A q£.�4 7
1b12r -17 II
Type of Water System Reason for Application,{ i,,,�1 p0 �
lY Pu,wCo mrunhy Well System(2 d more �l euddin9 perm f�14(7,.. 1
,,nneshons) ❑ Unnium of land'.
❑ Indlvidua wader source lore wlvrxAwn), a of Parcelsl_ SPL
❑ way ❑ Boundary line adluslment
/ ❑ Spdng/wnau water I ❑ Other leaplast
a Other(erylam e � 11 G ,.ntaron.T ❑ Replacement or Remodel(plea"wd"re name
(sr a waters slam below If applicable-no
If you have m than ore rasOonce curuwcmd d natum re cared)
to to,wee,chock ma pdtho'GrnnawMy water sg q
System bor
part 2: Water Connection lnformatlran
�dSiplete Ind section appre,nats for the type d water cnnnechon hwng evaluated
Public Water System
Namedwater System. 0 x-✓TL •i l 11 ----------._. .
WAinf Faddy lmerauy(wF1)Numbs:
lwda'mne'for aaofuerty) I
dl am the manager d the water system The water syet.,,IHs been app ved for
Theses. ,j�sarvices.
The e presently�_--.conneclw in use This w+ll be the=connection
0 I ern the manger d In*system This comlection-11 be to upgrade a change ihb use of an esislmg
cennar3iOn m this system(I e recme oi,,l to he time) Please lnd"te m the fdkheing fine the nalure
of this change
This MO1M"Vem K able and Man,W pmvlda water to this presin conneciasnls)we1oul estoseding
aw limit of the caste system or any an0.s set by Nate and bcal reget3tkkl
Signature d water System Deal `� I b A 4
This Nurn may be sunned aml availade for husk view at www co.mason>r.'•• . "-'
1 FII Nwe lkMml"n.a-.
Individual Water Wall
❑ Wafer all rayon(altache0 to apphcahon) Dept,_.... ft.
❑ Well Capacity Test(attached to appOrahar)
The well driller often performs wall capecdy tests at the time the well o construodd Resufts Iran
these Iesis are rwled W the wale)well repdn Resuhs from these tests will be accepted It the wafer
welt epon cannot be located by are applicant or a tbe water well report does not have a capacity test.
a well rapacity lest.which provices stabilization o!draw-down and recovary date,must he performed
by a hdenaed contractor
❑ Satisfactory bacteriological test(attach to appllcalwn)
Water Resource Inventory Area(WRIA)
Developmem within which WRIA hflp.!/g�.w mason.wa uglplAgptpg tIQ 15[]1q[—]22M
Water use re hmaation recorded. NIA_ pass__
Vile"Drtl@d _. _. __._.. . Daft-
Individual SpringlSodace Water
❑ WOOE permd(attach to apphwtion)
❑ Method of disinfection _
❑ 1 haw reason to believe That this water source can provide al least Egg gaWna per day.a"m
Provides wafer at a free Of 2 gallons per mmule based on the following ob"hes,ore
Author of Statement _ Date_
Reishonwhip to AORlo ant
Part 3: Mason County Community Satyricaa Evalwtlon(staff use only)
Satisfactory Determination ---__--- -
nvswtelm"ur"i1u hol edmers adeeuacy or the divribuuon p,thn guasittee an adequate Sur"Of
Rath mdefinitaly in the runia or m Y geana comyLarice mth all upWcable WOOL water m>rurw rtetlreiane.
Hecwmienped epproral ui .is,mowrdnenu ul Seoul,Code. Tit 6.C,hism 6666rp.Detarfnyysret of
Araruacylorduwpi,gparmitsare BPxh�. pdoiumat Gtowtlr Managenmml2pwfMNta{mpy apply Chapbr
3d 700%RCW
Unsatisfactory Determination.
Asserted"war",Supply dress rid repave adwarate to mere are,heft of V nonded use b the fig
reetret(q.
n reviewer's Signatures:
Emiron.kIli p/ .__..._ Date_
CSD Director. J Dap •a.