HomeMy WebLinkAboutWAT2024-00090 - WAT Application - 2/5/2024 WAT na 5yn
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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..Submit completed application, with any required attachments for review.
Ana roved buildin site Ian must accompany this a lication.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Darla Morin Date: 02/05/2024
Mailing Address: 3516 Canterbury Lane, Kent, WA 98032 Phone: 2063003089
Parcel Number: 42205-51-01039 Division -block-lot: 18-1-39
m�ner.
Type of Water System Reason for Application
J0 Public/Community Water System (2 or more ® Building permit 'j( D7O {�— Uo2U3
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑
❑ Spring/surface water Boundary line adjustment
❑
ElOther(explain) Other(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 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: LAKE CUSHMAN SYSTEM 5
Water Facility Inventory (WFI) Number 035290 (write"none'for two-party)
❑ I am the manager of this water system. The water system has been approved for Cervices. There
are presently connection(s)in use.This will be the connection.
d I 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: placing Manufactured Home on properly,part time residency
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 set by state and local regulation.
Print Name of Water System Manager JESSE MATHEWS Phone 360-877-2728
Signature of Water System Manager I.MA. — Date 02/05/2024
This form may be scanned and available for public view at www,co.mason.wa.us.
JCFH Foidet Deinking Wmcr Revised 427/2021
Individual Water Well
❑ Water well report (attached to application). Depth ft,
❑ Well capacity Test (attached to application) gpm 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 htto://gis.co mason wa_us/planning 14_ 15_16 X 22_
Water use or limitation recorded................................... i Yes
Well Drilled _....................._............. ........................ Date
Individual Spring/Surface Water
❑ 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)
FAppicant's
tisfactory Determination:
determination does not address adequacy of the distribution system, guarantee an adequate pQp of
er indefinitely in the future,or guarantee compliance with all applicable WDOE water resouro'd
ommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Determ�inati �'dTq
quacy far Building Permits are satisfied. Additional Growth Management requirements may apply. Chapl`e si,
0A RCW. ` p�
satisfactory Determination:
Pic
o water supply does not appear adequate to meet the needs of its intended use fertthd following
^ Reviewer's Signatures:
Environ. Health: /(,r/f Date V L
This form may be scanned and available for public view at www.u.mason.wa.us.
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