HomeMy WebLinkAboutWAT Application - 3/4/2024 WAT
415 N.6"Staet
MASON COUNTY Shelton,WA 98584
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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/ Parcel Identification
Name on Applicant: Laura EIS Date: 03/04/2024
Mailing Address: 330 NE lakerfdge Dr. Belfair,WA 98628 Phone: 360-710-6735
Parcel Number: 223047690080
Type of Water System Reason for Application
Ed PublirJCommunity Water System (2 or more Er Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springfsurface water ❑ Other (explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
ff you have more than one residence connected of water system below if applicable—no
to this waif, check the Publin Communify Wafer 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: Erickson Lake Tracts
Water Facility Inventory(WFI)Number. 54572W (write"none°for two-parry)
17 I am the manager of this water system. The water system has been approved for 42 services.There
are presently 23 connection(s) in use.This will be the Rom connection.
re
Ld 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: (esamw.noale) Fmm FuH bma Sm w M roll ame l
This water system is able and willing to provide water to this(these)connections)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Melissa Cox on behalf of NWS Phone 360-876-0958 ext. 104
Signature of Water System Manager,�71�/.P,/%lXq �,X on behalf of NWS Date o3/0412024
This form may be scanned and available for public view at vwvw co mason wa us.
Mm Po—m W-L-g Water R—,s 42712n21
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well rapacity Test(attached to application) gpm gpd.
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 rapacity 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 Hois.00mason-wa.us/planning 14_15_16_22_
Water use or limitation recorded................................... WA 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)
i Satisfactory Determination:
/ This determination does not address adequacy of the distribution system,guarantee an adequate supply of
I 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 6.6e.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reasori
Reviewer's Signatures: u
Environ. Health'. c(M Date3(� I
This form may be scanned and available for public view at www co mason wa us.
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