HomeMy WebLinkAboutWAT2024-00191 - WAT Application - 4/10/2024 WAT C)
415 N.6"Street
MASON COUNTY Sheltm,WA 99594
COMMUNITY SERVICES Sheltm:360-427-9670,EzL400
I lfatr:3W2754467,Eat.400
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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/ (P�arcel Identification
Name on Applicant: �Ity/hclrlT n-lh- - Data Li JID IZ`i
Mailing Address: [4101 kl f7eALrV IOt((Q.bt/Wone: LTZi �l'Z7�2Z
Parcel Number: 49099-4fi-P0131
Type of Water System Reason for
�Application
Ed Public/Community Water System(2 or more Building permit �
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ 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: South Side
Water Facility Inventory(WFI)Number: 056657 (write"none"for two-party)
Ed I am the manager of this water system. The water system has been approved for 6 services.There
are presently 4 connection(s)in use.This will be the 5 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(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 waterto 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 Brandy Milroy Phone 360-877-5249
Signature of Water System Manager � Date 05/28/2024
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This form maybe scanned and available for public view at www.co mason.wa.us.
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Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm dpd.
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 hap'figis co mason.wa ustolanning 140 150 16=22[']
Water use or limitation recorded................................... NIAQ YesQ
Well Drilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
{� ❑ 1 have reason to believe that this water source ran 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
t3: 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 rompliance with all applicable W DOE water resource regulations.
Recommended approval indicates requirements of Sanimry Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
fl Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
mason(s).
Reviewer's Signatures:
Environ. Health: \\\\„ � Y w I Date S Z
CSD Director:
Date 2 mf`
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