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HomeMy WebLinkAboutWAT2024-00264 - WAT Application - 6/4/2024 ENVIRONMENTAL HEALTH R UOa(D MASON COUNTY ShltmWA 894 JUN 25 2024 sheftm:3co.a27-%70,Ext 400 Public Health & Human SelrV T5 W. Alder Streef'ffir 360-2754467,Fx.400 Application for Determination of Water Adequacy Instructions 5 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 I , Name on Applicant: y. Date: (-.a\ C l ;�aL Mailing Address:$ S 1 lrTy 4' Phone: / i � (`p�n Parcel Number. r S 2ZM7-52—000aS Type of Water System Reason for Application �p Public/Community Water System(2 or more IV'Building permit e)LVR 02L1— 007(fl5 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 than one residence connected of water system below if applicable—no to this well, check the PublirlCommunity 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: i/f J CJ/h M'-fV C (4 Water Facility Inventory(WFI)Number. 837O t✓ (write-none"for two-party) L9' I am the mans er of)his water system.The water system has bee pproved fora/� services.There are presently=connection(s)in use.This will be the 5 W� 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(Le.: 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 loc I regulation. Print Name of Water System Manager rz"J / 11. 1 Phone Signature of Water System Manager 2 Date This form may be scanned and available for public view at www.masoncountywa.goy P: H Foetus\Driving Wager Revised W/02024 Pere 10172 Individual Water Well ❑ Water well report(attached to application). Depth fl. ❑ Well capacity Test(attached to application) opm opd. 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). 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: CC�� This determination does net address adequacy of the distribution system,guarantee an adegFia pp_(y of. / water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource r aBBas 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 a I Chap 36.70ARCW. d9q`p�„� � ^. 9 ❑ Unsatisfactory Determination: "��NTy 10?y .Applicant's water supply does not appear adequate to meet the needs of its intended use for the 4 reason(s). ��a "�'A�y`4 Reviewer's Signatures: //7// -Environ. Health: Dale ! l ! C V oL This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2