HomeMy WebLinkAboutWAT2024-00067 - WAT Application - 1/10/2024 WAT 9JDA4 - ()n0(o7
415 N.6O1 foes
MASON COUNTY Shchon,WA 91i
COMMUNITY SERVICES Shal. 36N429.9610,At4p0
Oclfav:M0-273d469,FM 00
r1,++�no�ear,wa,..x.x.nA�.�npw+v� H.I.360.48L3369,CM trq
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 bulldina site plan must accompany this application
Part 1: Applicantl Parcel Identification
Name on Applicant:Van Jeppesen Dater - 1/10/24
Meiling Addrem:16401 SE 352nd Aubum WA 98092 Phone: YSyAcg-4710 _
Parcel Number: 322207500040
Type of Water System Reason for Application
of Public/Community Water System(2 or more 13 Building permit 8l-b$LQA4-0043
connections) - ❑ Division of land.
❑ Individual water source(one connection), #of Parcels?_ SPL
❑ Well ❑ Boundary line adjustmert
❑ Springlaurface water
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(p[ease indiaK name
#you have more than one residence connected of water system bc:ow if applicable—no
to this weft,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: Patton �
Water Facility Inventory(WFI)Number. „r_ pr.,e„wii,.
(write'norlei two-party)
10 I am the manager of this water system The water system has been approved for _services.
There are presently 6 connection(s)in use,This will be the 2nd connection.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use o1 an existing
connection on this system(i.e.:recreational to full time). Please Indicate on the following line the nawre
of this change:
This water system is able and willing to provide water to this(them)connection(s)without exceeding I
the limits of the water system of any limits set by stale and local regulation.
rr <'II
Signature of Water System Managery�ili�el,euiS�dj�au;g Date 1/10/24
This foam maybe scanned and available for public view at www".:.imar.wa.us.
r.lEa E.Drui wa4r atve.Lv4f101e
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) opm 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 IA
Development within which WRIA http:l/gis.co.mason.wa.us/planning 14_15_16 22_
Water use or limitation recorded................................... NIA—Yes—
Well Drilled............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to appHcatlon)
❑ 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)
atisfactory Determination:
This determination does net address adequacy of the distribution system,guarantee an adequate soppy of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulators.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination or
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 fo meet the needs of its Intended use for the following
resson(s}
eviewer's Signatures: /
YvnEnvircn. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Pagc2of3