HomeMy WebLinkAboutWAT2024-00178 - WAT Application - 2/15/2024 MASON COUNTY 415 N.6"'sweet
Shelton,WA 98584
COMMUNITY SERVICES Shcuon 360-427-9670,Eat 400
Bel[elr:360-295.4467,Bat.400
bud Aing,Plannih ,line—eatal Health,Cmmmunlry Health Elil9: 360-482_5269, Lxt 4e0
Application for Determination of Water Adequacy
Instructions '3�t L,`�1' ��. (?j
1. Complete Part 1. No determination c!&.11de until Part 1 is fully comoleted
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 Applicant: (•J � ,� t Date. / ,�-l—
MailingAddressl�p-3-= '�,lr( \I "!-r ( S t x phone:
Parcel Number: ��-f) l�• ±� 1 •_ �i�\ � rs �
Type of Water System Reason for Application /���
4- Public/Community Water System (2 or more " Building permit 190)001eti 0015�1
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other El Other(explain) (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 PuhGc/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: 21;t {, p e CoMYhun l C/u.
Water Facility Inventory(WFI) Number. e�8 .j 7(J
� (write"none"for two-party)
14T I am the mans, r of this water system. The water system has b�eq approved for��W services. There
are presently _connection(s) in use. This will be the i / 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 and local regulation.
Print Name of Water System Manager Z�)Y"Hc"i �,q(� Phone
Signature of Water System Manager i Date -
This form may be scanned and available for public view at www.co.mason.wa.us.
J\Ell FonneA rinnklnu Winer Revised 427/1_021
Individual Water Well
Fthese
ll report (attached to application). Depth ft,
city Test (attached to application) gpm gpd.
driller often performs well capacity tests at the time the well is constructed. Results from
ts are noted on the water well report. Results from these tests will be accepted. If the waterrt cannot be located by the applicant or if the water well report does not have a capacity test,acity test, which provides stabilization of draw-down and recovery data, must be performedycensed contractor.
❑ Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA blip//gis.co.mason.wa us/planning 14 15_ 16_22_
Water use or limitation recorded..._.............................. N/A_Yes_
WellDrilled .........................................._....._............ Date
Individual Spring/Surface Water
FWDOE attach to application)
fection
o believe that this water source can provide at least 800 gallons per day; and/or
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:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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