HomeMy WebLinkAboutWAT2024-00274 - WAT Application - 6/17/2024 ENVIRONMENTAL
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MASON COUNTY ,�415 M.6°Street
Public Health & Human Services Ssel15 4so=27T4R00
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Application for Determination of Water Adecluac W A(der Street
Instructions
1. Complete Part 1. No determination can be made until Part 1 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
Name of Applicant: Cezary Nowowiejski Date: June 17.2024
Mailing Address: 2746 NW Rude Rd Poulsbo.WA 98370 Phone: (509)8685691
Parcel Number: 32021-58-01001
J Type of Water System Reason for Application
y Public/Community Water System (2 or more l(e Building permit jb QZR4 - 008 '3
connections) ❑ Division of land:
❑ Individual water source(one connection), p of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel (please indicate name
M you have more than one residence connected of water system below if applicable-no
to this wel), check the PublicJCommunity 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: Shorecrest Estates Water Company
Water Facility Inventory(WFI)Number: 78e20-1 (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.
1NJ 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: Existing Connection-Building Permit
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.
Print Name of Water System Manager Knstle HutcIn gn Phone (360)42"773
Signature of Water System Manager Date June 17,2024
This form may be scanned and available for public view at w .masonoourltYWa.aoy
r:\EBForms\A ng Water Reiseda MaO24 Page 1 of]
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Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
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 test,
a well capacity test,which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test within last year(attach to application).
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 regula ns.
Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Determin
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply.
36.70A RCW.
❑ Unsatisfactory Determination: -;'qs ✓U Q/'
Applicants water supply does not appear adequate to meet the needs of its intended use for the yang J v�
reason(s). UNn.
Reviewer's Signatures:
Environ. Health: Date
This form may be scanned and available for public view at www.masoncountywa.gov
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