HomeMy WebLinkAboutWAT2024-00295 - WAT Application - 8/6/2024 WAT 202-0 noZg�
MASON COUNTY RE��14
Shelton:360427-9670,Ext.400
Public Health & Human Services BelfnA.060-376-4AGWt 400
Application for Determination of Water Adego&at . U�L`Uet
Instructions I ( �1 6
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
Name on ApplicantL3 RLL-L Data:
Mailing Address:7J( Phone; a 5 • a--lt L{ 15 0C4
Parcel NumberP,—)Qt$Z - - On a--I C`d.Jt,,,�pt.�l LL�A `C4$
q Type of Water System Reason for Application
1�-Publir/Community Water System(2 or more 114- Building permit
/ connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water El Other(explain)
El Other(explain)
❑ Replacement or Remodel(please indicate name
1/you have more than one residence connected of water system below if applicable-no
to this welt, check the PubliclCommunity 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: A v ! Gff� n/ dr
Water Facility Inventory(WFI)Number. � (write"none-for two-party)
VII am the manager o this water system.The water system has en proved for services.There
are presently �'13T 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 or any limits set by state an
coall/egulation. -7/
Print Name of Water System Manager a ! V'n Ct Phone ,X AT VAL
Signature of Water System Manager /yj - Date 5 -� O l
This form may be scanned and available for public view at www.masonmuntywa.gov
]:t H Formsl Dunking Water Revuede1n M?074 Pege Ioft
S ,
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 drew-down and recovery data,must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource btve Area
Development within which WRIAhtti):ligis.m.mason.wa.us/[)Ianning 14_15_16_22_
Water use or limitation recorded...........----------......... NIA_Yes_
Well Drilled ............................................................... Date
Individual SpringlSurface 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;andfor
provides water at a rate or 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)
V\ Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarntee compliance with all applicable W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Tide 6,Chapter 6.66.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36 70A RCW.
i Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the fallowing
reason(s).
Reviewer's Signatures:
Environ. Health:
Date
This form may be scanned and available for public view,at wwvr.co.mason.vra.us.
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