HomeMy WebLinkAboutWAT2020-00183 - WAT Application - 6/1/2020 (2) WAT ?D20 -
MMWN UNi�'rY SERVICES RECENED
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415 N as Street,lisp e,Straorr WA985M.
Sh~:(aeo)427-WO ext 400 a aeltelr M 215-4467 Wd 400 a Elne:(M)4112-8 82 �.Atrial Sf/Bat
FAX(080)427-7787
Application for Determination of Water Adequacy
Instructione
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Part 1: Applicant/Parcel Identification
Name on Appikarlt �or_o+- Izts.SWss-' Date: G Zd
11C. Piro r0jrYj8�/D-383o
Parcel Number. /Z-ZZ 0150000/7
Type of Water System n for Application
b1irM,dnmunity water System(2 or more Idtrrg pemr5
oonnectlmp IT Division of tend:
❑ IndivWual water source(one mnnactlon), e Of Pam"? SPL
❑ Well ❑ Boundary fine W)ustment
❑ Springlsudace water ❑ Other(exptek)
❑ Other(**lain) ❑ Replacrnara or Remodel(please kdioa%name
Myou have more Man one reelrlence connected of water syves below If applicable-no
to this asp. check Me PubkCarmnWMly Wafer sipnshaa required)
System box.
Part 2: Water Connection Information
Complete the satbon appropriate for dre type of WSW connection being evaluated:
Public Water System
Name of water System:
Water Facility Inventory(WFq Number.
(wr9e'nona'fortwo-parry)
S[ 1 em Ile manager of w+Yrrystan.TM watereyMim been _
There are presently _ connect oMa)is wa.'IR*11�be the
❑ I am the memiew of this system.This oonnectim wilpla Ipprado or etwgtlM uteri
connection on this system(La.:rouaetlo el to full tYhe}. IrMkate on tlW IofidNYp
of this change:
This water system is able and willkW to WGIVI(le WMart ; live se)con nadlort(a)gtlrat '.:
the limits of water sysWn a arty I' try aYb basal reputation. '
Signature of Water System MWNQW Date
�tlaad
PrM ,t1. n ountyy D et.r.c
�pYin
Individual WoUr Well
❑ water wall report(attached to application). Depth e.
Cl Well capacity Teel(attached to appllatim) wm apd.
The wen drOw often performs well capacity tests at the fte Me wen Is mnetruclM. Raautte tram
Mores tab are noted on the water well report Results tram thou beet will be aooapb . if the water
well report cannot be located by Ma sppilciart or if the water well report doll not have a capacity teat,
a well capedly test,which provides stabniration of draw-down and recovery dab,must be padomred
by a licensed oenbeslor. - -
❑ Satietedory bacteriological test(attach to application).
Water Resource lr visinto Area )
Development within which V4M hco'//aia co mason.wa.uermtannlna
Water use or imitation recorded................................... N/A_Yes_
Well Drilled ............................................................... Dab
Individual SprinplSurface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 he"reason to believe that this water source an provide at bat 800 ganons per dry:andlor
provides water at a rate of 2 gellons per minute based on the fdbwhV obesrvadorm.
Author of Statement Data
Relafionship to Applicant
Part 3: Mason ftnty Community Servkea Evaluation(staff use on
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77,
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