HomeMy WebLinkAboutWAT2024-00246 - WAT Application - 9/10/2021 ,az�f - ooa
MASON COUNTY wnT
COMMUNITY SERVICES
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416 N es Sues. lb.Sidg 8.Shen WA NS84.
Sheson:(360)427-12e70 sat 400 a Belfair:(360)2754467M,100 a FJme:(360)4825268e104W
FAX(360)427-7787 �0�0
Application for Determination of Water Adequacy
Instructions
1. Complete Pan 1. No Oetennination can be made until Pen 1 is fully completed.
2. Complete only the portion of Pan 2 applying to the type of water connection ualmd.
3. Submit completed application,with any required attachments for review.
4. M ap2roved Wilding site pan must accompany this tipplitStib
Part 1: Applicant/Parcel Identification
Nameon Applicant Date: 9//DI Z.z,/
Malling Address: Hf.?$ 7Tly Al W,7-0 Phone: 253- 882- )%3 -
ParcmNumber. LW)Utit 14,'4 �RA4LS� lrtM 91a�bb `
Z'Looq— S)— poo is D J
Type of Water System Reason for Application
PubliUCommunlryWattic System(2 or more Buldurg pennittwAaq-
connections) ❑ Division of land:
❑ Individual water Source(we connection), paf Parcals7_ SPL
❑ Wall ❑ Boundary line adjustment rt11 ff��
❑ Spnng/suneoe water X Other("plain) 3�✓�1-fiU"�
❑ Other(explai ❑ Replacement or Remodel(phase indicate no me
f7 you have more than one msfdence connected of water system below if applicable—no
m this watt,check the PubAdCommsmilY Water sigrewre required)
Syafarn box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
T / Public Water System
Nameal Water System:
Water Fad6ty Inventory MR)Number. U1
1 /(write'bche'for two-party)
8 I am the manager of th,(s„wgter System.The water system has been ayrroyed for M&,services.
There are presently 1�L�_connedlon(s)In use.This we be Me 5 comroctlon.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(IA.:tacreadoml to full time).Please indicate on the following tine the nature
of this change:
T This water system is able and willing to provide water to this(these)connections)without eltceeding
the limits of the water system of any li (s set by state/dad brat regulat p
�� F Date
Signature of Water System Manager /
This form may be scanned and available Poc public view at vnNW co.maso�ni
ZbOls
mar romp oMen¢w.m�
Individual Water Well
❑ Walerweq report(attached to appllcadon). Depth n.
❑ Well capacity Test(attached to appdcaaon) apm gpd.
The well ddlar often performs well oapachy tests at fire time the well Is constructed. Reeults from
these taste are noted on the wale well report Results from Mae tests will be accepted.If the water
well report cannot be located by the appkard or if the water well report doss not have a capacity teat.
a wall capacity lest,whch provides stabilization of draw-darn and recovery data,must be performed
by a beensed contractor.
❑ Satisfaclwy bacteriological test(attach to application).
Water Resource Inventory Area(WRIA)
Development wleUn which WRIA'hyr!lots camas via s/ol in 14_15_16_22_
Water use ar ifthdadgn recorded................................... NIA Yes_
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ W DOE permh(attach to application)
❑ McOrotl ofdWnfectlor
❑ 1 have reeaon to belie,,that this water source can provide at least 80D gallons per day;andror
provides water at a rate of 2 gallons per minule based an the folbwbq observe6ans.
Author of Statement Date
Relationship to Applicant
Part 3: Mason Coun Community Services Evaluation staNuse only
Sallefactory Defem ination:
This dclenninetion does not address adequacy of dw dWribution ayaten,guarantee an adeioale soppy of
Recommended a approval lndcatos vrequiremonw e(SaNtary Cede.Till.6.C�per&i�(llAetemrWGon of
Adequacy for Building pemlw are sedsilk. Add tlonel Growth Management requirements may appy. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicant's wewrsupply core not appear adequate to meal Me race otlw Intended use fartha foilwwIng
Reviewer's Signatures:
Environ. Health: Reviewer's
!/ `
CSD Director:
Date 2.f2