HomeMy WebLinkAboutWAT2024-00303 - WAT Application - 8/12/2024 WAT
415 N.6'h Street
nMASON COUNTY Shelton,WA 99594
iWnt COMMUNITY SERVICES Shelton;360-427-9670,Ext.400
Bclfain 360-2754467,En 400
e�nam.rw„nae....... Elms:360482-5269,Ext 400
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: Applicantf Parcel Identification
Name on Applicant Linda Arnold Date: 08/12/2024
Meiling Address: 260 E Willow Blue Ln, SheBon,WA 98584 Phone: 360-280.3545
Parcel Number: 22132.11-90313
Type of Water System / Reason for Application
f� Public/Community Water System(2 or more H Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other("plain)
❑ Replacement or Remodel (please Indicate name
Ifyou have more then one residence connected of water system below it applicable—no
to this well,check the PubliclCommunky Wafer 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: Pine Tree Cove #2
Water Facility Inventory(WFI)Number: 04904F (write'none'for two-party)
I am the manager of this water system.The water system has been approved for 7 services. There
are presently 3 connection(s)in use.This will be the 4 connection.
❑ 1 am the manager ofthis 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 Melissa Cox on behalf of NW5 Phone 380-876-0958
Signature of Water System Manager• �/ "It"11 r-.1' on behalf of NWSDate 08/12/2024
This form may be scanned and available for public view at www.co.masen.wa-us,
LTH Emm6D ing AN at Rwuod417WM
Group B Water Systems
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C�'Satisfactory bacteriological test within last year(attach to application). 0�C , ,-fin, -—
/ Individual Water Well �""' �-
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) apm apd.
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 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
Part 3: Mason County Community Services Evaluation (staff use only)
)6LSatisfactory Determination:
lThis determination does not add...adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WOOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-Determination of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
-1 Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of Its intended use for the following
reason(s).
Reviewer's Signatures: /1
Environ. Health:�� Date �' �" 1
This form may be scanned and available for public view at www.masoncoun�a.gov,
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