HomeMy WebLinkAboutWAT2024-00308 - WAT Application - 7/30/2024 WAT
415 N.rA Street
MASON COUNTY Shelter;WA 98584
COMMUNITY SERVICES Shelton:360- ,ExL 400
aelfair.360-2754467275-0467,ExL 400
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Application for Determination of Water Adequacy
Instructions
1. Complete Pan 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 on Applicant: pAW W�].VyCt12% Date: `1 3-20 iL{
Mailing Address: 2bJ N.71AW kl ch 12A 06ti Jjf Phone: 36c-'No' c>345
Parcel Number: 520-14 - 13. 0000D Lor 5,)
J Type of Water System Reason for Application ,+�(
m Public/Community Water System(2 or more U( Building permit i3lUbjZaW-0l9
connections) gylAWA WA /2.)P, ❑ Division of land:
❑ Individual water source(one connection), If of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spnnglsurface 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 weft, check the Public(Community Water signature required)
System box.
_ IF16} C0f1y4eE}; fNl
Part 2: Water Connection Information 0 n
Complete the section appropriate for the type of water connection being evaluated: \rf
Public Water System O— w
Name of Water System: 1:;14AgA "d (WPII k DlQ'IXl,I Or, I'L
Water Facility Inventory(WFI)Number: V1t5V1P
(write"none'for two-party)
tL I am the manager of this water system.The water system has been approved for .2 services.
There are presently `7 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 (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 by state and local ulation.
Signature of Water System Manager Date 7 70.2OD-4
This form may be scanned and avail kite for public W at www.co.mason.wa.us.
]:\EHFame\Prmkmg Water R ndi 4/4/2038
Individual Water Well
R( Water well report(attached to application). Depth 46 ft.
Cd Well capacity Test(attached to application) "�5 apro gpd.
The well driller often performs well rapacity 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 rapacity lest,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 WRLA http://uis.co.mason.wa.us/plannina 14_15_16_22_
Water use or limitation recorded................................... N/A Yes
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
11 Part 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.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meal the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
EnAron. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of2
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U.N..2588 City.Some.Sn ROCHESTER WA 98579
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