HomeMy WebLinkAboutWAT2024-00251 - WAT Application - 11/7/2023 WAT
415 N.6-SUM
MASON COUNTY Sheltm WA 98594
BheaW:360-4z1-9610,Ext.400
COMMUNITY SERVICES
Be lm!360492-5269.Ext.400
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Application for Determination of Water Adequacy
Instructions
11. 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. Ana roved buildingsite Ian must accompany this a lication.
Part 1: Applicant/ Parcel Identification
Name on Applicant:
Lauren Fatnis,AgeM W Lemmr Northwest.Im Date: 1117/23
Mailing Address: 3M5561h A S U t I B F.&.1 Wav WA 9aW3 Phone: 12631308-0265
Parcel Number: 2 2 -0000u 1232 m°0a SN32
Type of Water System Reason for Application
�
® Public/Community Water System(2 or more ® Building permit 61-Dgop q
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Pa"Is7_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ 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
ff
Name of Water System: x n -- tAl akt�r �rsty 1cT I
Water Facility inventory(WFI)Number. 0135-
(write"none for two-party)
)W I am the manager of this water system.The water system has been approved for 1 0 services.
There are presently. connection(s)in use.This will be the R2,f connection.
❑ lam 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 folbwing 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 ny 1s set by sta and local regulation.
Signature of Water System Manager Data f f a 't
This form may be scanned and available for public view at wvnv co mason.wa.us.
Att'iscd 4�412x1 A
J:vai Forms\ITinkiny Water
Individual Water Well
❑ Water well report(attached to application). Depth it.
❑ 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 contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto:/Pois m.mason.wa.us/olanning 14_15_16_22_
Water use or limitation recorded..................................... N/A Yes_
Well Drilled ............................................................... Data
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
A 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 wild all applicable W DOE 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
3610A RCW.
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:
Environ. Health: Date
This form may be scanned and available for public view at tm vi.co.mason.wa.us.
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