HomeMy WebLinkAboutWAT2024-00244 - WAT Application - 5/28/2024 •_ - I MASON COUNTY WATia+aa44L
COMMUNITY DEVELOPMENT
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416 N 6&Street,Bldg S.Shelton WA SSW,
Shefton:(360)427-9670 ext 400 O Beifair.(360)275-4467 old 400 O EOna:(360)492-5i299 en400
FAX(360)427-7787
Application for Determination of Water Adequacy
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 buildingsite Ian must accom n this a lication.
Part 1: Applicant/Parcel Identification d �J
Name on Applicant: David and Kristine Stolle Date: f` Z `---
Mailing Address: 19308 25th Dr BE, Bothell 98012 Phone: 206 914 0299
Parcel Number: 32010-31-50180
Type of Water System Reason for Application
El PubliclCommunity Water System (2 or more O Building permit',' l(,i
connections) ❑ Division of land:
❑ Individual water source(one connection), v of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ other explaln)Sh ed Well
l,.p U V�—�a* ❑ Replacement or Remodel(please indicate name
H you ave m thaann ones si'denc connected of water system below if applicable—no
to th tl, check the PubiUCommunity Wafer 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: 4 /L ^C114 ("I r ptV.f�
Water Facility Inventory(WFI)Number:� ?+
(write'none'for two-party)
I am the manager of this water system.The water system has been approved for 91 services.
There are presently ? connection(s)in use.This will be the _connection.
❑ 1 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)Nithout exceeding
the limits of the water system or any limits set by sae and local regulation.
Signature of Water System Manager Date
This form may be scanned and available for public view at x.to.maa,iarad lr=l9.
JUIFO=m pnelunx Wmc
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm 9pd.
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 W RIA http j/ujs.co.masgn.wa.us/ Iammnc 14= 15Q 16=22=
Water use or limitation recorded................................... N/A_[=Yeses
WellDrilled ............................................................... 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 only)
atisfactory 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 6.66.040-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: 1/��` Date
CSD Director:
Date 3M2
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