HomeMy WebLinkAboutWAT2024-00291 - WAT Application - 7/31/2024 r
ENVIRONMENTAL WAT 9t) OD�
HEALTH
MASON COUNTICECEIVED 415 N.6te Street
3heho4 WA 98584
Bheltoe:360-027-9670,Ext.400
Public Health & Human Services
JUL 31 2024 Belfav:360-275-0467,Ext.400
W. Alder Street
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: Applicant/ Parcel Identification
Nameof Applicant: I?-oioec'f I^(lou gnus Date: 1.�0 -20W4
Mailing Address: 37 W.Sek:u`8It {-i'A Phone:
Parcel Number: 51917-57-00029
Type of Water System Reason for Application
J
N( PubliclCommunity Water System(2 or more 1a Building permit e)L gao`p ii, o?q
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
If you have more than one residence connected of water system below if applicable—no
to this well, check the PublicJCommunity 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: Lake Arrowhead
Water Facility Inventory(WFI)Number: 43600 3 (write"none'for two-party)
❑ 1 am the manager of this water system.The water system has been approved for_services.There
- / are presently 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 (i.e.: recreational to full time). Please indicate on the following line the nature of
this change: Active Connection
This water system is able and willing to provide water to this (these)connaction(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Brandy Milroy Phone 360-877-5249
Signature of Water System Manager i,A,ill Data 07130/2024
This form may be scanned and available for public view at wwvr.masoncountvwa.gov
1:\EN Forms\D,.bi Wafer Revised 05N82024 Page 1 d2
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Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well rapacity 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 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)
atisfactory 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 6.66.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
�I ^ . _ ^ ��Viq /1 _ s Signatures:
Environ. Health: A/ wVy\� � `/I"_t Date
This form may be scanned and available for public view at www.masoncountvwa.gov
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