HomeMy WebLinkAboutWAT2024-00052 - WAT Application - 11/7/2023 ENVIRONMENTAL
HEALTH WATaO - 0005
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MASON COUNTY Shelrov.WAA 985848584
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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 Applionl:tauren Ferule,Agant for Lenner Nort sst lm Date: 1117/23
Mailing Address: 3Mn65 Ave S.Unit 1-B.Fe eml Way WA gWC3 Phone: f253130&0265
Parcel Number: +z fz z&4
Type of Water System Reason for Application
® Public/Community Water System (2 or more 50 Building permit &Ma4` Lo I
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springlsurface water
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have more than one resilience connected of water system below t applicable—no
to this well, check the Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
p� pp Public Water System
Name of Water System:�l'yg" r.1J&IXt,
Water Facility Inventory(WFI)Number: O SdJ—O
(write"none"for two-party) ����
I am the manager of this water system.The water system has been approved for /�V]services.
There are presently_ 1& connection(s)in use.This will be the AXI 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(i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willing to rovide water to this(these)connection(s)without exceeding
the limits of the water system or an im' at by state d I regulation.
Signature of Water System Manager. Date yf i$ 13
This form may be scanned and available for public view at www.co.mason.wa.us.
J TH F.,m Dmking Wemr Rcviscd 4/4/2018
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm opd.
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 wall 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 RIA)
Development within which WRIA http://ois.co.masm.wa.us/plaM!M 14 16 16 22
Water use or limitation recorded................................... NIA 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 600 gallons per day;and/or
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Dale
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
'EicSatisfactory Determination:
This detennination 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 regulations.
Recommended approval indicates requirements of sanitary Code.Title 6,Chapter 6.66.040-Determination of
Adequacy for Building Permits am 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: '�" 1 Date (Z-t
This form may be scanned and available for public view at www.co.mason.wa.us.
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