HomeMy WebLinkAboutWAT2024-00262 - WAT Application - 6/27/2024 WAT o2 oo2�a
MASON COUNTY 1415 N.wn,W Street
Shelton,WA 98584
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Shelton:360 427-9670,ExL 400
Public Health & Human Services Belfair:360-2754"7,Ex44U0
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 building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name of Applicant: Cezary Nowowieiski Date: June 17, 2024
Mailing Address: 2746 NW Rude Rd Poulsbo,WA 98370 Phone: (509) 8685691
Parcel Number: 32021-58-01002
,../ Type of Water System Reason for Application
I4 Public/Community Water System (2 or more q/ Building permit &J2624
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
If you have mote than one residence connected of water system below if applicable—no
to this well, check the PublicrCommunity,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: 78620-1 (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.
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 any limits set by state and local regulation.
Print Name of Water System Manager Kristis Huinson Phone (360)426-0773
Signature of Water System Manager Date June 17,2024
1:\F3i Form¢\Ihivking Wager Rcvi O/OM024 Plg 1 of2
This form may be scanned and available for public view at www.masoncountywa.gov,
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 contmctor.
❑ 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
I
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.
�7 Unsatisfactory Determination: //��
Applicant's water supply does not appear adequate to meet the needs of Its Intended us'81�r �ypwing
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