HomeMy WebLinkAboutWAT2024-00296 - WAT Application - 8/6/2024 FAT ZoZ-i - Oo qte
MASON COUNTY 4r, A9veer
Shdteq WA98584
40 Shelton:360-427-9670,E 1.400
Public Health & Human Services Deltan 360-275-4467.Fxt,400
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 I
Name on Applicant:V0 V) ski'1Ct, 4t� Date. rr S" li ' 2-4
Mailing Address: I(-I u Phone: \?J&•'190- bW
Parcel Number: �LYhip,�f W,1" -A Qeif6ij U1610H - I I --003o
Type of Water System Reason for Application❑ Public/Community Water System(2 or more Building permit T>V1 20 Z A - Wq lP
connections) ❑ Division of land'.
Individual water source (one connection), $of Parcels? SPL
X Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel (please indicate name
If you have mare than one residence connected of water system below if applicable-no
to this well, check the Public/Community 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:
Water Facility Inventory (WFI) Number: (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.
❑ am the manager:ofhis system. This connection will be to upgratle or change the use of an existingconnection on thitem (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 and local regulation.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.masoneountywa.gov
P\EH Fors\Drinking water Itcv—d 0 510 8/20 24 Yage I oft
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
` / Individual Water Well Q/ 7
p Water well report(attached to application). Depth �cft. f/I l 7l�v
/� Well capacity Test(attached to application) io gPm N�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
FDOE permit(attach to application)
ethod of disinfection
ave reason to believe that this water source can provide at least 800 gallons per day; and/or
ovides 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 6.66.040-Deteminadon of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW. 'y
Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures: f� ry 61G1L
Environ. Health: f,%/ Date
This form may be scanned and available for public view at www.masoncoun�a.gov
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