HomeMy WebLinkAboutWAT2024-00135 - WAT Application - 3/11/2024 • WAT -
MASON COUNTY
COMMUNITY DEVELOPMENT
c `P Famil AuizGna U.'a'Bundlnc Planning
415 N 6-Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 sd 400 a Belfalr: (360)275-4467 eM 400 0 Elms: (360)482-5269 eA 4"EnE'
FAX(360)427-7787 l� ED
Application for Determination of Water Adequacy
MAR 112024
Instructions 6
1. Complete Part 1. No determination can be made until Part 1 is fully completed. er Street
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 ''11II rr --
Name on Applicant—� o li a' ;L-J .wt.3
Mailing Address: to3 l= (a" e-ksy"} Phone: (ss3� 8o - loZZA
°d"` 98589
Parcel Number. 1��32520�00 t
Type of Water System Reason for Applica
Public/Community Water System (2 or more ❑ Building permitoup
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
1 ❑ 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 wail, check the PubliclCommunity,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: ��ci�c \)Aex-10;-O ri c3r 4' t
Water Facility Inventory(WFI)Number. QS35)
(wits'none for two-party)
�1 I am the manager ofs water system. The water system has been approved for hLoLservices.
/ There are presentty connection(s)in use.This will be the 9i50 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 provide water to this(these)connection(s)without exceeding
the limits of the water system o ny li set by state and cal anon.
Signature of Water System Manager Date 2 23 �Z
This form may be scanned and available for public view at www.co.mason.wa.us.
P: Fn.\Donlon,Weer Revised 1R92M
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 http flais.co.masonma.us/planning 14=15=16=22=
Water use a limitation recorded................................... N/AQ YesQ
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 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 on/
\ )Satisfactory Determination:
17— This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits am satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
C Unsatisfactory Determination:
Applicanfs water supply does not appear adequate to meet the needs of its Intended use for the following
reason(s).
�/n K� x/��nn C,Reeviiewer's Signatures: I I
Environ. Health: g " t I Date
CSD Director: Date Z°r'