HomeMy WebLinkAboutWAT Application - 2/28/2024 WAT
415 N.a Street
MASON COUNTY Shelton,WA 99584
COMMUNITY SERVICES Shelton:3W.427-9670,ExL 400
Belfuc 360-2754467,Ext.400
mrdmaw.,mgem��m.n.ixrrn.ce,,,,,..xn Rdm Elmo:360-482-5269,EA.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part t 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 % (y
Name on Applicant �KIh'l w'1LLrYt �dO d�rn� Date: �z�' y/�/J
Mailing Address: /so /IG U �7W Phone: 34D-9�pA90-665q
Parcel Number: �� _7j � 6I 7i 0LJ 000 (3,e/F&I/- G4
Type of Water System Reason for /A1�pplicatiyon
t3. Public/Community Water System (2 or more Building permit-5Y� X`*'
,4 connections) ❑ Division of land:
A6yindividual water source(one connection), #of Parcels? SPL
Jii( Well ❑ Boundary line adjustment
❑ Spring/surface water
Other(explain) MIA /3 n /[_ pig 0k56❑ Other(explain)
eM, d o fheeho4e +re ❑ Replacement or Remodel(please indicate name
If you have more than one residence connected YW h L of water system below if 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:
Public Water System
Name of Water System:
Water Facility Inventory(WFI) Number:
(write"none"for two-party)
1 I am the manager of thin water system.The water system has been approved for_services.
There are presently 't connection(s)in use. This will be the Y-Fh connection.
I am the manager of this sy li ection will be to upgrade or change the use of an existing
connection on this system 'recreational to full ' Please indicate on the following line the nature
of this change:
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/state and local regulation. U
Signature of Water System Manager Date
This rearm may be scanned and available for public view at www.co.mason.wam
1?EH Forms\Drinking Wawr Revised 4IOWI S
Individual Water Well
Water well report(attached to application). Depth ft.
lit Well capacity Test(attached to application) gpm 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.
�Q Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hlty,//gis.co.mason.wa.us/olanning 14_ 15_16_22_
Water use or limitation recorded................................... N/A_.�__Yes_
Well Drilled ............................................................... Date 1983
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 only)
❑ Satisfactory Determination:
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 WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Tale 6,Chapter 6.68.040-Determination of
Adequacy for Building Pernits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A ROW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: �— !101&2jLfeDate
This form may be scanned and avails le for public view at www.co.mason.wa.us.
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