HomeMy WebLinkAboutWAT2024-00284 - WAT Application - 7/26/2024 WAT - c�as�w
MASON COUNTY RECEIVED Sh 15.6elm,WA6
COMMUNITYSERVICES 584
Shchon:360-427-9670,Ext.400
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g ,b W. Alder Street Elms:360482-5269,Ext.400
Application for Determination of Water Adeq&NVIRONMENTAL
Instructions HEALTH
Complete Part 1. No determination can be made until Part 1 is fully completed.
Complete only the portion of Part 2 applying to the type of water connection utilized.
Submit completed application, with any required attachments for review.
I An approved building site plan must accompany this application,
Part 1: Applicant/ Parcel Identification
Name on Applicant: OLDS,Aaron 8 Kathleen Date: 7-26-2024
Mailin Address: 12520 SW 18TH ST 36
9 BEAVERTON OR 970084623 Phone: ( 0) 369-2967
Parcel Number: 12119-50-00104
Type of Water System Reason for Application
Public/Community Water System(2 or more &d Building permit
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ( P )
❑ 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 PubliGCommunity 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: HARTSTENE POINTE WATER-SEWER DISTRICT
Water Facility Inventory (WFI) Number: 31569-0
(write"none"for two-party)
4 1 am the manager of this water system. The water system has been approved for A89 services.
There are presently 479 connection(s)in use.This will be the 480 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)connections)without exceeding
the limits of the water system or any limits_-setbystate and local regulation.
Signature of Water System Manager Date 7-26-2024
•
This form may be scanned and available for public view at www.co.mason.wa.us.
ME Fomu1 Drinking Water Revised 4I4I2018
Individual Water Well
❑ Water well report (attached to application). Depth fit.
❑ Well capacity Test(attached to application) apm 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(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hftp�//qis.m.mason.wa.us/l)lannina 14_ 15_16_22_
Water use or limitation recorded................ .................. N/A Yes
WellDrilled ............................................................... 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 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)
Satisfactory 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 6.68.040-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).
Reviewer's Signatures: O,
Environ. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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