HomeMy WebLinkAboutWAT Application - 5/7/2024 W AT
MASON COUNTY 4f6N. A985
Shelton,WA 98654
ShWton:360427-9670,Fat.4W
Public Health & Human Services eelhiro 360-275-4467,Ext.4W
Application for Determination of Water Adequacy c�
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 wafer 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 on Applicant: A S"�7'JL� (,a L'� Date: l
Mailing Address:'3 L I ^i i I A0�Q 5,S L� ' c-''1 r -z
Parcel Number: aa-o, ekgsz)
Type of Water System v Reason for Application
Public/Community Water System(2 or more l3 Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdngisurface water ❑ Other(explain)
❑ Other(explain) O Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below if applicable—no
to this well, check the Public/Community 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 W Water System: fWf'S 61
y
Water Facility Inventory(WFI)Number. 9�37U! 1 (write-none'for two-party)
ell, am the manag is water system.The water system has htoq aooroved forLI r u services.There
re presently connection(s)in use.This will be the 5Y connection.
,am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this aKstem('.e.: recreational to full time). Please indicate on the following line the nature of
this change: ' S�n h
This water system is able an willing to provide water to this (these)connection(s)without exceeding the
limits of the water system or any limits set by state an
Io�,af/{regulation. /�� ''ter
Print Name of Water System Manager j vlei Phone 36 ���, V ';g
Signature of Water System Manager Dale S J
This form may be scanned and available for public view at wvvw masonoountvwa.9ov
J:\Ea Fosms\DnrJsing Water
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Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Welt capacity Test(attached to application) gpm dpd.
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 par minute based on the following observations.
Author of Statement Date
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (Staff use only)
17 ;Sattsfactoiy.Determination guarantee an adequate soppy of
This determination does not address adequacy of the dish6buLgn system,
water indefinitely in the future,or guarantee compbance wrtp all applicable WDOE waxer resource regulations.
Recommended approval indicates requirements of Sanitary Code Title 6,Chapter 6.68 040-Delemanalion 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). -
Revi wer's Signatures:
,Environ. Health: Date
This farm may be scanned and available for Public view at willrnasaxoumtvwa-tsav
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