HomeMy WebLinkAboutWAT2023-00370 - WAT Application - 12/20/2023 �w dD230C8a0
MASON COUNTY WAT -
_
COMMUNITY SERVICES �b63S�O
Buildinry Pbwl, F'immenpl H-e Commmily He4M 3q I �d of Tro-ke
415 N V Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 P Belfair.(360)276-4467 ext 400 o Elma:(360)4825269 ext 400
FAX(360)427.7787
Application for Determination of Water Adequacy
Instructions
11 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 7: Applicant/Parcel Identification
Name on Applicant: KQfinQ^V,�anr� tlou Date: 1L-70 Z0Z3
Mailing Address: `i 00'a RJI�l.�- L ST .Phone: 5W- 789- (PT3 1
Parcel Number: 3212�- 51-OD 1"IS , "WA Q19513
Type of Water System Reason for Application
Public/Community Water System (2 or more K Building permit
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 Public/Community Wafer signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
'' ,^, 11/' I Public Water System
' c�
Name of Water System: t xkt- I�f I ler�db LOLJtti c�tls"t'2,1yy
Water Facility Inventory(WFI)Number:4y l� d
(write"none"for two-party)
7- 1 am the manager of this water system.The water system has been approved for I�5q7 services.
There are presently M19 connection(s)in use.This will be the _connection.
0, 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.: r reational Q full tim ) Please mclicatee,on the following line the nature
of this change: �QAI I B'1 1��A Al 1 hrt J
This water system is able and willing to provide water to this (these)connection($)without exceeding
the limits of the water system or any limits t-set
��l.fibtb/py��state and local regulation.
Signature of Water System Manager�{/t,L(, ' Date
This form may be scanned and available for public view at ywww.co.masonma.us,
I:TH Forms\Dnnk ng Water aevimi 1012018
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) apm 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 htto:/tais.co.mason.wa.us/planning 14=115=]16=]22=
Water use o limitation recorded................................... N/A_=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 B00 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)
tisfactory 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 WDOE 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:
Appliranrs water supply does not appear adequate to meet the needs of its intended use far the following
reason(s).
�Reviewer's Signatures: 1 ^�
EnAron. Health: `�-d'7 't+-v" �I v• ' Date ` I( /
CSD Director. Date z�rz