HomeMy WebLinkAboutWAT2024-00224 - WAT Application - 4/29/2024 RECEIVED
29 Zp24 MAY 16 2024
A� onnu 615 W. Alder Street WATQO a4 - C)0 '2 R
y\aaon 415 N.6°Sear
MASON COUNTY Sbdtos,WA9a594
COMMUNITY SERVICES Shdme:360427-9670,Ext400
Belfeb:360-275-4467,Ext 400
a oa,¢ew+.q,a,wo, uxwincanm,.wrx.dm Elrac 3604923269,Ext.400
Application for Determination of Water Adequ��iRONMENTAL
Instructions HEALTH
1. Complete Part 1. No determination can be made until Part i 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 bulkling site planmust accompany this application,
Part 1: Applicantl Parcel Identification
Name an Applicant: SLAYN k U(A VAcrra u l+ Date: 4.21- 202$
Mailing Address: 1240 INS L.*SDN Wxy Phone: 366•2-0 •1ItS
Parcel Number: M11 I S10012Z
Type of Water System Reason for Application
Hl' PublidCommunity Water System(2 or more Building permltg�D�oay-�V connections) ❑ Division of land:
❑ Individual water source(one connection), #of Paroels7 SPL
❑ Well ❑ Boundary line adjustment
❑ Spdnglsudace water
❑ Other("plain) ❑ Other(explain)
❑ Replacement or Remodel(please Indicate name
N you have more then one residence connected of water system below if applicable-no
to this well, check the PubliclCommuntfy 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: b-a,z1 (/al,
Water Facility Inventory(WFI)Number.. n<,l (O -
(write'none"for two-party)
c
I am the manager of this water system.The water system has been ap for J Z 'services.
There are presently `i r;'1 connection(s)In use.This will be the D connection.
❑ I 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 or aCny limits 7476y al@te and local regulation.
Signature of Water System Managed -->� ) Dale
This form may be scanned and available for public view at www.co.mason.wa.w.
J.T11 F—\Drinking Weer Ae oM 4142018
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ 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 lest,
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 (Vill
Development within which WRIA http�/ldis.00.mason.wa.us/plannina 14_15_16_22_
Water use or limitation recorded................................... N/A Yes
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:
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,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ 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: Date
This form may be scanned anh available for public view at www.co.mason.wa.us.
rap 2 of z