HomeMy WebLinkAboutWAT2024-00003 - WAT Application - 12/27/2023 MASON COUNTY
COMMUNITY SERVICES
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415 N 6-Street,Bldg 8,Shelton WA 985 1,
Shelton'.(360)427-9670 etn 400 O BelfFr(ir (38 ;75-0 1678 ext 400 O Elms,(360)482.5269 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. Ana roved buildingsite Ian must accompany this a lication.
Part 1: Applicant/ Parcel Identification
Name on Applicant: CHANG,Judy Date: 12-27-20
9215N FORTUNE AVE phone: (971) 533-0773
Mailing Address: POrtT'M OR 972032673
Parcel Number: 12119-53-000,'t0
Type of Water System Reason for Application
10 Public/Commundy Water System(2 or more [9 Building pemlit BLD"4- 00013
connections) ❑ Division of land:
❑ Individual water source(one connection), k 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 Public/Communify,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: HARTSTENE POINTE WATER-SEWER DISTRICT
Water Facility Inventory(WFI)Number. 31569-0
(write"none"for two-party)
Ed am the manager of this water system.The water system has been approved for 489 services.
There are presently 476 connections)in use.This will be the 477 connection.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(Lis: recreational 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 any limits sefl ystate and local regulation.
-/"
1
Signature of Water System Manager �'� - � Date 12-27-2023
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This form maybe scanned and available for public view at www.co.ma n wa us.
Revised In_srzma
F,U?H Forms\Drinking\corci
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) opm clad.
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 11a s co mason wa usiplamninc 14_IS_16_22_
Water use or limitation recorded..................... N/A_Yes_
WellDrilled ............................................................... Dale
Individual SpringlSurface 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 detemination 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 regulators.
Recommended approval indicates requirements of Sanitary Code,Tine 6,Chapter 6.68040-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 needs of its intended use for the following
Maim s).
Reviewer's Signatures:
Environ. Health:
Date
�rrz
CSO Director: Date