HomeMy WebLinkAboutWAT2024-00242 - WAT Application - 5/24/2024 W AT 2 - Llaz` ;,
415 N.6-Street
MASON COUNTY Shelton,WA 98594
COMMUNITY SERVICES Sheitav:360-427-9670,Fx 400
aelfart:360.2JSJA67,Ext 4W00
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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.
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 ApplicantMPMVenture group LLGJoDerek JohnsonDate: 05/24/2024
Mailing Address:110 W K street-Suite C Shelton,WA 98W Phone: 253-226-2808
Parcel Number. 223365100024
Type of Water System � Reason for Application /y�/
V Publir/Commundy Water System(2 or more Y Building permit 13iGi 'L02'� -WV7O
connections) ❑ Division of land:
❑ Individual water source(one Connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(pease 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: Lynch Cove Div 1
Water Facility Inventory(WFI)Number: 07079W (write"none"for two-party)
Vi am the manager of this water system.The water system has been approved for 38_services.There
are presently 38 Connection(s)in use.This will be the 38th connection.
El nrt r1
❑ 1 am the manager of this system.This connection will be to upg'T3d'e or h3ngEt�iCuse a an exassbng
Connection on this system(i.e.: recreational to full fime). 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.
Print Name of Water System Manager ,M/p,e^l�_issa Cox on behalf of NWS phi 360-876-0958
Signature of Water System Manager e7!'llt'ljflf 61•.!'on banairor Nws Date 05/2412024
This form may be scanned and available for public view at www.mmilson.wa.us.
J:THF.m Drinking Wmer Reviud4CJ/2021
Individual Water Well
❑ Water well report(attached to application). Depth fl.
❑ Well capacity Test(attached to application) qpm gpd.
The well driller often performs well rapacity 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 A the water well report does not have a capacity test,
a well capacity test, which provides stabilization of draw-clown and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area elll
Development within which WRIA htto://ais.co.masm.wa.us/olannina I IS 16_22_
Water use a limitation recorded................................... WA Yes
WenDrilled............................................................... Date
Individual SpringMurface Water
❑ MOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to befieve 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 on/
Satisfactory 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 am 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
reason(s).
Reviewer's Signatures:
Environ. Health: .. h
This form may be smnncd and available for public view at Winn .N^UNWa M •is
P.,2of2