HomeMy WebLinkAboutWAT Application - 7/23/2024 WAT
415 N.6°Srrem
mn, 98 Shel WA t 400
Shelton:36P42to, ,A 594 MASON COUNTY
COMMUNITY SERVICES 6elf.io 360-2754467,Ext.400
tram��� Elm.:360482-5269,Ext 400
Application for Determination of Water Adequacy
Instructions
2 Complete PaPart 1
rt 1. No determination coobntothe type of water connection ly lutilized.
e until
2. Complete only the portion of Part 2 applying
3. Submit completed application,with any required attachments for review.
4. Ana roved building site Ian must accompany this application.
Part t: Applicant//Parcel Identification
Name on Applicant: t'1�'10Y1L�G. l �l ln0 0-la Date: 2'-�
�—
MailingAddress: ��E. h�Llu<. — hone: 51e�-(J �1�
Parcel Number: ulplln -53-��Q�3
Type of Water System Reason for Aplplllicnation ,.,r,pq
XPublic/Community Water System (2 or more Building permit T)lc.t, 09-4 -rb 'D
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well qF
adjus en❑ Spnng/surface water )❑ Other(explain) or Remotlel If you have more than one residence connectedm below if ato this well, check the PublialCommunity Waterired)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
` 11 Public Water System
Name of Water System:
Water Facility Inventory(WFI)Number:
(write'none-for two-party)
❑ 1 am 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.
This
ll
to
ade or
e the use
an existing
❑ connection on I am the 9h s system(i.e.:er of this recrea recreational toifull ton ime).Please rindicate onnthe following fline 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 any limits set by state and local regulation.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Revised 4AM1.
J.ViH Forms\Drinking W.ter
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 hftp'//pis co mason wa.us/olaMing 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 rote 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 onl )
❑ 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 WDGE 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:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: k"*' QVLI-Date
This form may be scanned and available for public view at www.co.mason.wa.us,
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