HomeMy WebLinkAboutWAT2024-00227 - WAT Application - 8/24/2023 WAT ,-WR4
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MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360427-9670,Eu.400
B.I is 360-2754467,Ext.400
e�sx yaanm,y Em.aa.i x-Ift%I—,wa1& Elm:360482-5269,Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part i 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: Sam Madfn,Agent f Lenmr Nalhwest,Inc Date: 8/2412023
Mailing Address: 334556fh Ave S.Un81-B.FedwW Wav WA 98w3 Phone: f2W)294-1322
Parcel Number. 142MI-WI30 'Fa Future HS413
Type of Water System Reason for Application
® Public/Community Water System (2 or more ® Building permit 13LbRoI4 -00(01-7
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springisurface water
❑ Other(explain) ❑ ReplacOther ement )
❑ Replacement or Remodel(please indicate name
It you have more than one residence connected of water system below#applicable—no
to this waif, check the PubficlCommunity 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 of Water System: �fi� rP Ly&At�46+,k * I
Water Facility Inventory(WFI)Number. 657850
(write'none'for two-party) ''�
P I am the manager of this water system.The water system has been approved for services.
There are presently 79L conneaion(s)in use.This will be the I-V connection.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection m 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 will'n to provide water to this (these)connection(s)without exceeding
the limits of the water system or ny Its set by sia an local regulation.
Signature of Water System Manager Date 8 2
This form may be scanned and available for public view at www.co.mason.wa.us.
39EH Fame\Drinking Water Rain 4I4n018
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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 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(aosch to application).
Water Resource Inventory Area (WRIA
Development within which WRIA httoitois co mason.wa.us/planning 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 lead 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)
J Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinhely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Tfie 6,Chapter 6.68.040-06terminafion of
Adequacy for Building permits are safistied. Additional Growth Management.requirements may apply. Chapter
36.70A RCW.
1 Unsatisfactory Determination:
Applicants 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 fomt may be scanned and available for public view at www.co.mason.wa.us.
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