HomeMy WebLinkAboutWAT Application - 1/4/2024 n�N WAT
v�RON MASON COUNTY
EN N�P�-j K COMMUNITY DEVELOPMENT".E C E I V E D
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415 N 6e Street,Bldg 8, Shelton WA 98584, JAN —4 2024
Shelton:(360)427-9670 ext 400 4 Belfair:(360)275-4467 ext 400 4 Elma:(360)4825269 ext 400
FAX(360)427-7787 i l( \IV. Alder Street
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Pan 1 is fully comoleted.
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: Scott Boyer Date: 12/16/23
Mailing Address: 12216 Corliss Avenue N SeatuglPhone: 206-235-0935
Parcel Number: 32022-50-00901
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ❑O Building permit
connections) ❑ Division of land:
l7 Individual water source (one connection), #of Paroels? SPL
Well ❑ Boundary line adjustment
❑ Spring/surface water `✓❑0 Other(explain)
❑ Other(explain) �R iplaceme or Remode lease indicate name
Iryou have more then one residence connected of water sys applicable—no
to this well, check the Publir✓Communify Water ��naturele�lr y 1 _ D x�x� /
System box. fllJJ�(f��-l(/�(i/J�IJi (XJ` /lLn
Part2: 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:
(write"none"for two-party)
❑ 1 am the manager of this water system.The water system has been approved71inethe
.
There are presently connection(s)in use.This will be the
❑ 1 am the manager of this system.This connection will be to upgrade or changting
connection on this system(i.e.: recreational to full time).Please indicate on thnature
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 limits set by state and local regulation.
Signature of Water System Manager
Data 12/18/23
This form may be scanned and available for public view at wwa.co.mason.wa.urs.
J'\EH Pmms\lNinkinB worn
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm 9Pd.
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 lest(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http*//qis.co.mason.wa.us/plaaning 140 1 5=16E=]22=
Water use or limitation recorded................................... N/Aj�YesQ
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE pemtit(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 p ter re0--Oe ernn ation regulations.
Recommended approval in Chapter dicates requirements of Sanitary Code,Title 6, pter
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).
Reviewer's Signatures:
Environ. Health: Yi7" r ' y Date
3 af2
CSD Director: Date