HomeMy WebLinkAboutWAT2024-00079 - WAT Application - 7/25/2023 WAT oL4-SDQQM_
415 N.be'Sheen
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Belfoo:360-2754 70,EX.400
13elt.n:360427-9670,ExtEX.400
�w.<om n.Hwm Elms:360482-5269,Ext.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 a plication.
Part 1: Applicant/ Parcel Identification
Name on Applicant Sam Martin.Agar for Lennar Northwest,Inc Dale: 7/25r2020
Mailing Address: 33455 ath Aw S Unit 1-e Federal WaywA,9S003 Phone: (253)2W322
Parcel Number: M 'For FUWre HS p54
Type of Water System Reason for�A1p�plicati�ton
® Public/Community Water System (2 o more ® Building pemlil 7)I-DXnzl -Q0I-6
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPl
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
if you have more than one residence connected of water system below if applicable-no
to this well, check the PublicJCommunity 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: 7W-141r1 wo,�
Water Facility Inventory(WFI)Number. OS"3S�0
(write"none"for two-parry)
pfl I am the manager of this water system.The water system has been approved for 1 it services.
/ There are presently -77A connection(s)in use.This will be the 2 connection.
❑ 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.:recreationai to full time).Please indicate on the following line the nature
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 a ft set by state an cal r grlation.
Signature of Water System Manager Dale E! I
This form may be scanned and available for public view at v-:v co.mason.Wa.us.
1:� Farm\D alcn8Water
aeiw vv2ou
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity 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 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 http,iiciis.co.mason.wa.us/plannincI 14_15_1622
Water use or limitation recorded................................... N/A.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)
jSatisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarani"compliance with all applicable WDOE water resoume regulations.
Recommended approval indicates requirements of Sanitary Code,Tire 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:
Appimanra water supply does not appear adequate to meet the needs of as intended use for the following
reason(s).
�Re/v✓ie�wees Signatures: (-,
Environ. Health: Dale
This form may be scanned and available for public view at www.00.mason.wa.us.
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