HomeMy WebLinkAboutWAT Application - 5/10/2024 RECEIVED
MAY 21 2024 WAT 6 1
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Application for Determination of Water Adequacy HEALTH''
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 ApplicanC Jason Campbell(applicant) Date: S110/2024
Mailing Address: 11211 133rd St E.Puyallup,WA 98374 Phone: 253-241-35M
Parcel Number: 323095110001 COLONY SURF 2 BLK: 10 LOT: 1
Type of Water System Reason for Application
X Public/Commur,dy Water System(2 or more D Building permit ,L•1�anaU— 60(03
connections) ❑ Division of land: VV 1
❑ 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
IT you have more than one residence connected of water system below it applicable-no
to this welt.check the PublicyCommunny 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: COL eV li, jW GL t4e WATSle
Water Facility Inventory(WFI)Number: /�(090 .8
(write-hone-for mo-party)
❑ 1 am the manager of this water system.The water system has been approved for_services.
There are presently connections)in use.This will be the connection.
Pf I am the manager of this system.This connection will be to upgrade or charge 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: (/PCBMe fetM[.L If
'Y mr
This water system is able and willing to provide water to this(these)connections)without exceeding
the limits of the water system or any limits set by stateand local regulation.
Signature of Water System Manages-6 rj/ Data
This form may be scanned"an4ndd available for public view at�.
I lFH Ymre\De.ki,Waer RenrW Y@eIN
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Individual Water Well
❑ Water well report(attached to application). Depth a.
❑ Well rapacity Test(attached to application) apm gpd.
The well driller often performs well capacity lasts at the time the well is constructed. Results from
these tests are noted on the water well repair. 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 slabilizadon of draw-down and recovery data,must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area IA
Development within which WRIA hop:Naieco.mason.wa.uslylannim 14151622
Water use or limitation recorded................................... WA Veit
Well Drilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water spume can provide at least 800 gallons per day;ancuor
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 determination does nor address adequary,of this dmircutton system,guaranis.an adequate supply of
water Indefinitely in me future,or guarantee compliance with all applicable W DOE water rmource mgulations.
Recommended approval indicates requirements of Sanitary Code,Tithe 6,Chapter 6 fi8.040-Determination of
Adequacy for Building Permits am satisfied. Additional Growth Management requirements may apply. Chapter
36,70A RCW.
C Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet Iva needs of its intended use for the following
reasonis).
Reviewer's Signatures:
Environ. Heaf(h: Data
6�2' I�-1
This form may be scanned and available for public view at www.co.rnason wa.us.
PW 3 or2