HomeMy WebLinkAboutWAT Application - 8/15/2024 WAT -�
MASON COUNTY <i ,WA Siren
Shelton,0, 1.400
8584
Shelton:360A21A610,Ext. t00
Public Health & Human Services adfvr 36o-ns-Id07,Et1.4W
Application for Determination of Water Adequacy
Instructions A�G15
1. Complete Pan 1. No determination can be made until Part 1 is fully completed. RF 1p2
2. Complete only the portion of Part 2 applying to the type of water connection utilized. C V
3. Submit completed application with any required attachments for review.
4. Ana roved buildingsite Ian must accom n this a ication.
Part 1: Applicant/ Parcel Identification
Name of Applicant. Date: a I ILL
Mailing Address: Q]%M Phone: an- sql
Parcel Number: I gwolt-k- G, �w c�
Type of Water System Reason for Application
B' Public/Community Water System(2 or more B(Building permit-Tenorv'r 111',yt-pveYnehA'
connections) ❑ Division of land
❑ Individual water source(one connection), d 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 H applicable—no
to this weld, check the PublicyCommimity 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'. -PekGry v l
Water Facility Inventory(WFI)Number: 0517app (write"rwne'fortwo-party)
❑ 1 sm 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.
Er I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(is t recreational to full time). Please indicate on the following line the nature of
this change: R lhadd �490"b
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 and local regulation.
Print Name of Water System Manager_ / _Ll) Phone �M�&"O�•Z7S`-3nOb
Signature of Water System Manager Date 7- 7
This form may be scanned and available for public view at www.mamncountfM.aov
lain Fmnal prinking Waw Iinvi ,d I)i,C) i P,p+e of3
Group a Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft
❑ Well capacity Test(attached to application)_ pm
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 teals 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 teat,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 SpringitSurface Water
❑ WDOE Penn@(attach to application)
❑ Method of disinfedbn
❑ I have reason to believe that this water source can provide at least 800 gallons par 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)
Satisfactory Determination: _
This determination does not address adequacy of me distribution system,guarantee an adequate supply of
water indefinitely in the future,or qua mome compliance with all apphicable MOE water resource regulati
Recommended approval indicates requirement,of Sanitary Coda,Tithe 6,Chapter 6.66.040-Oetenorati Adequacy her Building Permits are satisfied. Additional Growth Management requirement,may apply, C 36.70A RCW.
❑ Unsatisfactory Determination: ''pr,',' �
Applicants water supply does not appear adequate to meet the reads of its intended use for Ihe9igarpsng reason(a). .
Environ Health Reviewer's Signatures: ( ��//OG�NryyO'Y�vq s1p1f O
. : Data—J�1.�`G��-.F q �FHT
This form may be scanned and available for public Ylaw at www,mawncourrtvwe aov
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