HomeMy WebLinkAboutWAT2024-00250 - WAT Application - 6/4/2024 WAT17oZ�I
MASON COUNTY 415 W ASeed
A 915841
SW.:340.42]-%]e,Ed.400
Public Health & Human Services BeHair 36 -275446],Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is WY 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 apprcvecl buildino site plan must accompany this aplAcation.
Part 1: Applicant! Parcel Identification
Name on Applicant�z��� /l'i ice . !1 �LW Dole:
Mailing Address: 1C.f— V 0*f cSf T nnw.a co Phone: 253 -�4-1
Parcel Number1��A.-rC)OQ
Type of Water System Reason for Applicatiiion ,� ��sc]
f� Public/Community Water System(2 or more ❑ Building perms a 1 -Ow/e l
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
ff you have more man one ning dance connected of water system below d applicable-no
to this well, check the Pub0aCklmmrmlty 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: AAe nn 11 l
Water Facility Inventory (WFI)Number ��` r. r •1 (wma'none'for two-party)
❑ 1 am the manager of this water system.The water system has been approved for=services.Thera
are presently - connection(s)in use.This will be the conneclioo.
❑ 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 lull time).Please indicate on the following line the nature of
this change:
This water system is able and wfl ing to provide water to this(these)connaction(s)without exceeding the
limits of the water system or any limits set by state and local regulation. ���`�
Print Name of Water System Manager 1 1 Phone SICV�—� +
Signature of Water System Manager FYI' Date 7 "
This form may be scanned and available for public view at www.masonoountvwe.gov
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Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) apm gpd.
The well duller 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 hfti),/Iqis.co.mason.wa.us/plannincI 14=15=16[ ]22=
Water use or limitation recorded................ .................. N/AQ Yeses
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
Pa 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,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
C 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 �1
CSD Director.
Date orz
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