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HomeMy WebLinkAboutWAT2024-00078 - WAT Application - 2/13/2024 � 4 WAT ;?oaJ - 000-76 415 N.6t Street MASON COUNTY Shelton,WA 985M COMMUNITY SERVICES Shelton:360427-9670,Eat 4W Belfafr.360-2754467,En 400 Ehna:360482-5269,Ear.400 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/ Parcel Identification Name on Applicant: Henry Kostelecky Date. 02/13/2024 Mailing Address: PO Box 1661, Hoodsport, WA 98548 Phone: 253 973 5849 Parcel Number: 422095400094 Division-block-lot: 1794 Type of Water System Reason for Application Public/Community Water System(2 or more © t BO- 1a Building permit connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ ReplacOther ement ) ❑ Replacement or Remodel(please indicate name ff 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: LAKE CUSHMAN SYSTEM 5 Water Facility Inventory(WFI) Number: 035290 (write'none"for two-party) ❑ I am the manager of this water system.The water system has been approved fort__aervices.There are presently connections) in use.This will be the connection. d I 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: Remeationat to single family msidenm 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 limits set by state and local regulation. Print Name of Water System Manager JESSE MATHEWS Phone 360-877-9668 Jere Mathews Signature of Water System Manager--^=---_- __ __-_ Date 02/14/2024 This form may be scanned and available for public view at www.co.mason.wa.us. ]:1EH Forms\Thinking Water Rev 4/272021 s - Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) opm gpd. The well duller 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 drew-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 hftp://gis.w.mason.wa.us/planning 14_15_16_22_ Water use or limitation recorded................................... N/A Yes WellDrilled............................................................... 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 the 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 need$of its intended use for the following reason(s). Reviewer's Signatures: 2 v Environ. Health: Date This form may be scanneA and available for public view at www.co.mason.wa.us. Page 2 of 2