Loading...
HomeMy WebLinkAboutWAT Application - 2/20/2024 MASON COUNTY COMMUNITY DEVELOPMENT Permit A5515tana Center,Building,Planning 415 N 6"Street. Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 -5 Belfair (360)275-4467 ext 400 Elms: (360)482-5269 eat 400 FAX(360)427-7787 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 Name on Applicant: JOSEPH BUILDERS NW Date: . Mailing Address: Yj l it Illy I✓k 14 N 1 � L)(�Phone: Parcel Number: 22221-52-00059 Type of Water System YP Y Reason for Application ❑ Public/Community Water System (2 or more OO Building permit 6111 C'IG21y connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well❑ Spring/surface water ❑ Boundary line adjustment (e xplain) p❑ Other(explain) ❑ ❑ Replacement r Remodel please indicate name if you have more than one residence connected of water system ow applicable—no to this well check the Public/Communny Water signature required) System box. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated. Public rWater System FNarne of Water System: UJLl.1`1G Y {41 L7 ter Facility Inventory(WFI) Number: (write"none"for two-party) I 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. 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. 1-AIi1I 6ovneA Drinking Water RevisM]/=018 Individual Water Well ❑ Water well report (attached to apphcatlon) Depth _ft Well capacity Test (attached to application,) _ gpm gpd. 1 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. ❑ Satlsfactery bacteriological test (attach to application). I Water Resource Inventory Area (WRIA) Development within which WRIA r _ _ r a i-c 14_15 18_22 Water use or limitation recorded._.._. ......... .... NIA Yes_ Well Drilled _.. Date Individual Spring/Surface Water f ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ I 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 a,adequatesupply 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 6.68040-Determination of Adequacy for Building permits are Satisfied Additional Growth Management requirements may apply. Chapter 3670A RCW Unsatisfactory Determination. Applicants water supply does not appear adequate to meet the needs of its intended use for the following reasons) Reviewer's Signatures: �Environ. Health Date -- This form may be scan If-_ ned and available for public view at www.co.mas_on.wa.us.