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HomeMy WebLinkAboutWAT2024-00111 - WAT Application - 2/14/2024 WAT � nnIII -a 415 N.6' Street MASON COUNTY Shelton,WA .400 COMMUNITY SERVICES Shelton:360-275-4467.EA.400 Helfair:360-275-4467,Ex[.400 ax;uou q.,,,,my,e�.;.r, ,.,ma nnuw ramm�mrn=am Elma 360-482-5269.Ext.400 Application for Determination of Water Adequacy Instructions 11. 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. Ana roved buildingsite Ian must accompany this o l'cation. Part 1: Applicant/ Parcel Identification Name on Applicant: Kevin Bouwman Date: 02/14/2024 Mailing Address: PO Box 354, Hoodsport, WA 98548 Phone: 4254447832 Parcel Number: 422095400010 Division-block-lot: 17-10 Kavp fruwlxox ' Type of Water System Reason for Application JO PubliclCommunity Water System(2 or more © Building permit f1161'U12r{-DDRtsg connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surfaoe water ❑ Other(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 PubliclCommunity 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-parry) ❑ I am the manager of this water system. The water system has been approved for'll s rvices. There are presently connection(s) in use.This will be the connection. 91 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 thischange: newconstmction 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 360-877-9668 Signature of Water System Manager,w..^­— —1-1 Date 02/14/2024 This form maybe scanned and available for public view at www.co.mason.wa.us. MEH Forms\Drinking Water Revised 4/27CO21 Individual Water Well ❑ Water well report(attached to application). Depth R ❑ 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 Higis co mason wa us/olannino 14_15_16_22_ Water use or limitation recorded................................... N/A_Yes_ WellDrilled ............................................................... 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; an dlor 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 on/ atisfactory 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: Applicants water supply does not appear adequate to meet the needs of Its intended use for the following mason(s). Reviewer's Signatures: Environ. Health: /( Date y This form may be scann d and available for public view at www.co.mason.wa.us. Page 2 of