HomeMy WebLinkAboutWAT2024-00256 - WAT Application - 11/7/2023 r WAT 0a�5(v
415 N.6'e Street
MASON COUNTY Sbehm WA 985M
0 COMMUNITY SERVICES Shenon:360427-9670,ExL 400
Uffir 360-2754467,Ext 400
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Application for Determination of Water Adequacy
Instructions
1. Complete Pad 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Pad 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 atccorneany this application.
Part 1: Applicant/ Parcel Identification
Name on ApplicantLeumn Farms.Agent W Lerner Nordwe4 Inc Date: 1117123
Malling Address: 334556th Ave S Urit 143 Federal Wav wA gap03 Phone: (253)30"265
Parcel Number: 123 21-011000 12a V s'F>FNun Hs#1a1
Type of Water System Reason for Application
® Public/Community Water System(2 or more ® Building permit a(�aDa T-W I I
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
N3rou have more than one residence connected of water system below it applicable-no
to this welt,check the Public/Community Water signature required)
Syslem box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
^� Public Water System r
Name of Water System: fSUtnt f f.,Y.axt:t- tr54'/Gt l*
Water Facility Inventory(WFI)Number. 65 3 ro
(write"none"for two-party)
)9. I am the manager of this water system.The water system has been approved for services.
There are presently 92,"? connection(s)in use.This will be the 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 (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 oraffify—tlmits set by state nd local regulation.
Signatu a of Water System Manager Date (t /
11 ll 1
This form may be scanned and available for public view at www.ep.mason.wa.ru.
3:1EH Fonnrl Drinking Werer RwvW 4/NI01 g
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ 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 9 the water well report does not have a rapacity 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 httpl;cis.co.mason.wa.usfolamang 14_15_16_22_
Water use or limitation recorded................................... IQA 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 B00 gallons per day;andfor
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:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee cornpllance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of sanitary Code,Title 6.Chapter 6.68.D40-Determination of
Adequacy for Building Pernits 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).__
Reviewer's Signatures:
Environ, Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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