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Home My WebLink AboutWAT2024-00029 - WAT Application - 12/13/2023 INIASON COUNTY COMMUNITY DEVELOPMENT ennn4.nos.c.no,e,.mw.•rr...r r a15 N 6-Street,all 8.Shelton WA 98584, Shelton (360)427.9670 ant 400 c- ae8am(3601275- 67 ea 400 4 elma'I36014A2.5269 eat 400 FAX(3601427.7767 Application for Determination of Water Adequacy Instructions 1. Complete Part 1. No determination can be made unfit Part 1 is fully completed. 2. Complete only the Portion of Part 2 applying to the type of Water connection ubtized. 3. Submit completed application.With any required anachments for review. 4. An approved building site plan must accompany this application Part 1: Applicant! Parcel Identification Name on Applicant: Lake Devereaux LLC Date: 12/13/'2023 Mailing Address: 9126 Mullen Rd SE Olympia WA Phone 360-790-0110 Parcel Number: 12207-50-00019 Type of Water System .t Reason for Application Cl� Public/Community Water System(2 or more ry Bwld'ng Dermrt connections) ❑ Division of Iii ❑ Iadnadual Water source(one connection(, pot Parcels' ,SPL ❑ Well ❑ Boundary line adjustment ❑ Spnnglieurtaca water ❑ Other(explain)_____-___ Replace _. ment Remode n l nweas ind,at.na'rir� It you have more than one residence connected em below f aopfcable - no to this well,tick the Pubb.CDmmumly Water signaWro required) R System box. Part 2: Water Connection Information { Complete the section appropriate for the type of water connection oemg.valuated. Public Water System Name of Water System: LAEEL)Cl7G� MLC'Aof-. AGGoc—t4-hCiv'1..� Wets Facility mventory(WFI)Number: V - ' (write'none'fornw-parry) � � F•CI S�'t 117-1 I am the rnanager of this water system.The water system has peen appr vetl for z?servicesThere are preeenlly 2,�connectmn(s)In use.This will be the connection❑ 1 am the manager of this system.This connection will be to upgrade or change lye use of an existiconnection on this system Ile:recreational to Il lime). Please in lcate on the following line me Vrof this change: Q(n =Thiswatersystem is abl nand willing to provWe w far .lhls(these) rnection(s)without exceedi limits of the water system or any mi set tat nit to r on, t/IZ�24 nature of Water System Manager Data 12/13/2023 Title;form may be scanned and available for public view at wyrW,c,masQn.wa ulus / HI hx,m UnNmg N=a, c�... . .. . -. Irv-...� Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) gipm 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 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 WRlA http,//Qis.co.mason.wa.us/planning 14015D 16=]22=1 Water use or limitation recorded................................... N/AQ 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) atisfactory Determination: This determination does not address adequacy of the distribution system,guarantee an adequate supply of water indefinitely in the future,or guaramee compliance with all applicable W DOE 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: Applicanfa water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Re isyrygr's Signatures: ^ / Environ. Health: 'I�) Date CSD Director. Date 2°f 2