HomeMy WebLinkAboutWAT2024-00140 - WAT Application - 3/12/2024 IWATao
�C1 MASON COUNTY
p`.atS` COMMUNITY DEVELOPMENT
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Shelton:(360)427-9670 e#400 4 Selfa (360)275-4467 e#00 * EIma:(360)4825269 e#400
V FAX(360)427-7787 RECEIVED
Application for Determination of Water Adequacy
MAR 12 2024
Instructions
�1. Complete Part 1. No determination can be made until Part 1 is full com I W Alder St eet
2. Complete only the portion of Part 2 applying to the type of water connection u ilt
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 r1 t-��
Name on Applicant:{-1- KL /If S Data: Tom\
Mailing Address: Phone: D '
Parcel Number: '2�=Ley) - SD —:10 D(}�
Type of Water System ,,( Reason for Application
PublictCommunity Water System(2 or more 1" Building permit o L,paoa 7- o C)Z J Jg
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
N you have more than one residence connected of water system below it applicable-no
to this well, check the Publia 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: 0&4g00-D
(write'none'for two-party)
❑ lam the manager of this water system.The water system has been approved for_services.
There are presently connection(s)in use.This will be the connection.
l<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). Pleare indicate on the following line the nature
of this change: fvt_�l:uo � M�1/a /nnn R'on
This water system is able and willing to provide water to this (these)connection(s)without exceeding
the limits of the water system or anylimits set by state apd local regulation.
Signature of Water System Manager",,&�..d/i el / Date Q Qa
This form may be scanned and available for public view at www co.mason wa.us.
P.\EH Forms\Dnnlmg Wma Rev nit 1125/2018
Individual Water Well
❑ Water well report(attached to application). Depth k.
❑ 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.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto/loisco.mason.wa.us/planning 14C:_—]15016=j22=]
Water use or limitation recorded............................... N/AII_Yeses
WellDrilled ............................................................... Dale
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,Tile 6,Chapter 6.68.040-Determipation of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply-'Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of is intended use for the —WA
reawn(s). .
^� Reviewer's Signatures: t./ rFNVRONMfN 4
Environ. Health: /( Date l Z 4H��T
H
CSD Director:
Date z nf2