HomeMy WebLinkAboutWAT2024-00034 - WAT Application - 1/23/2024 (ti ff�}_ - o -4—
MASON CnMMI COUNTY
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Application for Determination of Water Adequacy
Instructions
�Pml 1 is lolly co pleted.
Z.Pan 1. No delemt paid 2 can be made un of water connection WhzM
141
npkte only the ponian of Pan 2 applpng to the typhmeMs br review.
bmit completed application,with any required anac
SErOved tit d Dian must eccanDa in,,this SPPiicatbn
Part 7: Applicant/P'a1rcel jdentification i}�
Name on Applicant �y,L �' Q;b4[C-A {`G.CFII` Date: ,� t����
Mailing Address' (-0SbeIM""Phe"°� fk�-St---✓6't� q-----
Parcel Number 22 n 19 -SO^ 1011, _
Type of Water System Reason for Application
Building milt BI,D;LW4-000V'
8. connections)
Water System(2 a more n
IndWualw ❑ Divisionofs?—
❑ Individual water source(one connection). #01 Panels? SPL---_—'
❑ Well ❑ Boundary line adjustment
❑ Spnng/surfacewaler ❑ other(expuun)
❑ Other(explain) ❑ Replacement a Remodel(please indicate name
ff you have more Man aria residence connected of water system below it appfcabb-no
to this we®check Me Pub iOCommunity Water signature required) ' \
System box. �v
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(WFI)Number' o OL- D
(wme'none'for two-party)
I am the manager of th water system.The water system has been app ved for _services.
There are presently =nacnon(s)in use.This will be the Conneckion.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on Nis 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 provid ater;th (tftse)connection(s)without exceeding
the IrcnAs of Me water system a any lim�s leulaiN
Signature of Water System Manager Date
This form may be canned and available for public view at www co mason wa.us.
r Ul ramp DruJ+nc W. Rai> 12�POIR
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm opd.
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 htto//ais.co.mason.wa.us/olannino 14075=]16=]22=1
Water use or limitation recorded................................... N/A_L::]_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 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 me distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary 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.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
IIan ,��t,,R,teviewer's Signatures: (,�
Environ. Health: KIM 4IU ,/// Date /
CSD Director: paw 2 oft
WATER FACILITIES INVENTORY (WFI) Quarea o3 osrzaz4
�� ,yam s � FORM
I*Health ONE FORM PER SYSTEM Pointed. 3/5/2024
�,r 1.1w," WFI Printetl For: OmDemand
o�1W�.,.,a,,.waa. x Submission Reason: Contact Update
RETURN TO: Central Services-WFI, PO Box 47822,Olympia,WA,98504-7822 or email wfi@doh.wa.gov
1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP S. TYPE
60407A CADIAWOOOS MASON B
6.PRIMARY CONTACT NAME S MAILING ADDRESS 7.OWNER NAME S MAILING ADDRESS
CHARLE LEISTER CHARLE LEISTER
8312 SE LYNCH RD 8312 SE LYNCH RD
SHELTON,WA 98584 SHELTON,WA 98584
STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE.
ATTN ATTN
ADDRESS ADDRESS
CITY STATE ZIP CITY STATE ZIP
9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION
Puri Contact Daytime Phone: Owner Daytime Phone:
Primary Contact Mobile/CeII Phone: (360)339-3685 Owner Mobile/Cel Phone. (360)339-3685
Primary Canted Evening Phone: Owner Evening Phone:
Fax: E-mail: Fax: E-mall:
1.SATELLITE MANAGEMENT AGENCY-SMA(check only one)
X Not applicable(Skip to U12)
Owned and Managed SMA NAME: SMA Number
Managed Only
Owned Only
12.WATER SYSTEM CHARACTERISTICS(made all Net apply)
Agricultural Hospital/Clinic Residential
Commercial/Business ❑ Industrial ❑School
Day Care ❑ Licensed Residential Fall ❑Temporary Farm Worker
Food Service/Food Permit ❑ Lodging ❑Other(church,fire station,etc.)'.
1,000 or more person event for 2 or more days per year ❑ Recreational I RV Park
3.WATER SYSTIEM curnifiefill(mMk only am) - 0. GE 90 tons)
ciAesociation Cl County ClInveator Special District
FANG
n Federal Private Slate 2.500
i6 17 18 19 20 21 22 23 24
SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
is
m p 4 m O
IUTVS NAME FOR SOURCE F M O A D m
WELL TAG ID NUMBER. 4 4 c o, = m pyD n P
Example: WELL 91 XYM6 m m F p x ,asi fin p �F w�F^An^ E ; P +pr 0 s f A p yp1 w g Q{y
i IF SOURCE
ISPUNTESURCHASED OR IED, NTERTIE
F - w 0 f 31 r D g O n i D p is 0 D 24 z} Is S Z
3 LIST SELLER'S NAME ID m �n m = 9F. m 1• s Irl m 2 ? A O hh y i
S Example: SEATTLE NUMBER r b 6 O 6 O P a t P + A < a m i i i 5 P y� m� z a v m
501 WELL p1 X % X 280 15 SE NW 29 20N 02W