HomeMy WebLinkAboutWAT2024-00180 - WAT Application - 4/8/2024 WAT )n
MASON COUNTY
COMMUNITY SERVICES
BuiidFy 14n,in9 EmIrnmMJ N�Itlu rmmmnllr HV IM
415 N 6-Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670W400 O Bellaw..(W0)2754467eM400 a EInv:(380)4825269ext400
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 potion 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 succompany this application.
Part 1: Applicant/Parcel Identification I, �,,�te� /Q
Name on Applicant: G 'fllt�f( D e:
Mailing Address: hone: f(I/ t7 • .^(gip ' S11 `�
Parcel Number: Wf223- 77- 9,221e1
Type of Water System Reason for IA�pplication /�
1A Public/Community,Water System(2 or more X Building permit fJiL, 4-(,1(�` 41
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Wall ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below ff applicable—no
to this well, check the Public Community Water signature required)
System tax.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated;
Public Water System
Name of Water System: 9L12.Ar. *'4
Water Facility Inventory(WFI)Number. ti'4.29qf�
(write°none"for two-party)
i
'12\I am the manager of thi@ Water system.The water system has been approv for services.
There are presently�.__cornection(s)in use.This will be the connection.
❑ 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:
This water system Is able and willing to provide water to this(these)cunnecton(s)without exceeding
the limits of the water system or any limits set by state and Zonal regulation.
Signature of Water System Manager v T Date
This form may be scanned and available for public view at Nmww.co.mason.wa.us.
):NPl1 F—N 13-1ch,W. arieN 1/35r1�18
Individual Water Well
❑ Water wall report(adached to application). Depth ft
❑ Well capacity Test(attached to application) aPm apd.
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 lest,which provides sbibilioaWn of draw-down and recovery data,must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area(WRIA)
DeveI..
hich WRIA hlto'I/aie co n ova us/planning 14(]15�16�22r-]
Watern recorded................................... N/AQ Yes,=
Won ................................................... Dale
individual Spring/Surface Water
Cl WDOE p
ermit to application)
❑ Method
[10 1 have believe that this water source can provide al least 8Do gallons per day;and/or
providel a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant
Part 3: illason County Community Services Evaluation staff use only
-Satisfactory Determination:
This delem ination does not address adequacy of the disetbudon system,guarantee an adequate supply of
water indefinitely In the future,or guarantee compliance wain all applicable W DOfer 8 terOes�1e regulators.
Recommentled approval indicates requeements of Sanitary Cade,Title 6, p
Adequacy for Bulltling Pertniis are saecfied. onel Gma?h Man�agoment requitaQey apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear ad to meal the needs of its Mended case for the fdlowing
reason(s).
�
^Mo �:�L4V„(/"il Revl'ewerS SlgnaWres:
Environ.Health: , Date
1 :oa
CSD Director: Date
CERTIFICATE OF WATER AVAILABILITY
PART A-TO BE COMPLETED BY APPLICAN�,�T7
PROJECTADDRESS R1 G. ClnrtrAG � -• APPLICATION No.
SUBDIVISION/PROJECT NAME ) PARCEL 22223'l�
Proposed water usage_(#connections) Customer type(circle one ural residential
Residential Multi-family Commer us at
1, the undersigned, or my appointed representative have requested the following purveyor to certily willingness and
ability to provide the Indicated service. 1 have read and understand the information provided by the water purveyor
on this Certificate, and acknowledge that the proposed pm*ct may require Improvements to the water system,
which would incur my financial obligation. Prior to final approval for construction of the water facilities, it Is
understood that a legal contract between myself and the water utility, which specifies the terms of water service,
operational responsibility, and financial obligation, may be required. I further understand that this Certificate of
WawAvailability will expire three(3)years from the date it was issued to me.
Dµhits( EGSIe ' Av A
PRINT NAME Troi F A& er F,&%11tV SIGNATURE ] pia R�7
ADDRESS nQ 8Q )t 1A)Le CITY c er6nSTATEZIP gV337
NOTE: Peninsula Light Company requires that an Application for Water Service be completed prior to Issuance of a
Certificate of Water Availability. Please contact the Water Department at(253)357.1511 for an Application form.
PART B-TO BE COMPLETED BY WATER PURVEYOR
Water system to provide service R67 -)1• �'-f State ID# OLIa 9q F
The proposed developme6
/is not within our approved service area(circle one).
This water ui will not be providing service(circle one).
This water system is- is not eslgned to handle irrigationisprinklor systems(circle one).
-Provi ' oor water use is reasonable and not during peak demand periods.
Approved number of connections_ (D Existing source capacity &0 (gpm)
Number of cunendexisting users t4 Existing storage '— (gallons)
Treatment provided? Yes (No)Circle one). Water quality concerns: r 0>1i!-
It is suspected that some residential plastic plumbing material may promote iron/sulfur
bacterial growth. Although these bacteria do not necessanly pose any health concerns,
possible sulfur(rotten egg)odor may develop. Please advise your plumbing contractor.
Wat service will be provided by:
Direct connection to approved, existing water main.
_Extension of existing water main(s).
New water system in accordance with WAC 246-290 and Pierce County Ordinances 86-117S3 and 92-99
Are water system facilities approved according to DOH requirements? S II ,IN �
11 f�Pl1
Water service will be made available to this project by(date)yDyCJ--r -nS1QI�A O,rl 5
Z ldep"aterfto sMater availability rorm.doc Page 1 of2 Rev. Sep 2007
CERTIFICATE OF WATER AVAILABILITY
PROJECTADDRESS 31 E. ci l C*• APPLICATION No.
SUBDIVISION/PROJECT NAME lot ID—D PARCEL 1222 3--7-7- 170064
FIRE FLOW INFORMATION(FOR ALL PROJECTS-SINGLE FAMILY RESIDENTIAL, MULTI-FAMILY,
COMMERCIAL OR INDUSTRIAL WATER MAINS):
Location of nearest main capable of supplying at least 750 GPM
If not in street at front of property,distance from property to above feet. O/A R,410 )v
Fire flow available at 20 psi is pmfw minutes. yta, pVA�,ablPf
Estimated static pressure at project n is psi. (If greater than 80 psi tt is recommended that
customer install a pressure re g valve)
HYDRANTS:
Distan center line of property frontage to nearest hydrant measured along routes of fire apparatus travel
feet. Hydrant number
THE AMOUNT OF AVAILABLE FIRE FLOW INDICATED ABOVE IS IN ADDITION TO REQUIREMENTS FOR
NORMAL DOMESTIC MAXIMUM USE.
A WATER SYSTEM VICINITY MAP WHICH SHOWS THE WATER MAINS AND HYDRANTS SERVING THIS
PROJECT IS REQUIRED FOR All PROJECTS. r
A contract as has not been signed with the applicant for water service. (circle one) C-Onl tee pai�
The above information is an accurate account of the existing or necessary water system facilifies.
FOR PRELIMINARY SHORT PLAT OR SUBDIVISION:
We understand that this document, in absence of a legal contract, constitutes certification of willingness and ability
to provide water service. It is further understood that, in the absence of an approved comprehensive plan,
additional engineering approval has been obtained which demonstrates that facilities to provide water service to
this project are available or can be constructed.
Water Purveyor Peninsula Light Company Water Department Date
Signature Title Phone
FOR FINAL SHORT PLAT,SUBDIVISION, BUILDING PERMIT,SEPTIC DESIGN:
We, the undersigned water purveyor, certify that we will assume full operational and maintenance responsibility for
the above water system,which has been designed, approved and installed'in accordance with Washington
Administrative Code 246-290, RCW 90.44(Water Rights Permits), Pierce County Ordinances 06-117S0 and 92-99,
and an approved water system comprehensive plan.
Water Purveyor Peninsula LI ht Com any Water Department Date r �7- i
Signature /Tff/77t fDw-u2� Title t- Phone.ZS3-RS7-5�7f
•A Bond or Assignment of Funds(please attach)is acceptable for final land division applications only.
T This certificate of water availability is only good for three years from date issued.
ZJdapawatarflmm Ater avallability fom.doc Page 2 of Rev. aep2007
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