HomeMy WebLinkAboutWAT2024-00176 - WAT Application - 4/5/2024 WAT 'LO _
MASON COUNTY 415 N.6-S0eet
Shelon,WA 985M
COMMUNITY SERVICES Shelton:360-427-9670,&R 400
Eelfair:360-275-4467,Ext 4
e�nemy.ne�,nn,g.E„„,a, ,n,i xa,�mmn,n..,mn n<,im Elma:360-482-5269,Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No detenninatlon 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 P1an must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: XcwrKL lr .. N Date: 2y
Mailing Address: 1811 Pans,clam RO r Lau yA�01 hone: 7io - L42--01 a9
Parcel Number: 213 I 1 to
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more bd Building permithJlG�202`I - yd
connections) ❑ Division of land:
81 Individual water source(one connection), p of Parcels? SPL
El Well El Spring/surface water ❑ Boundary line adjustment
❑ 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 PublicXommunity 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:
Water Facility Inventory(WFI)Number:
(write"none'for two-party)
❑ I am the manager of this water system.The water system has been approved for services.
There are presently connection(s)in use.This will be the connection.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system (he.: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)connection(s)without exceeding
the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
1:\EHFame\Drinking Water R. ,V42O18
Individual Water Well
eIt, Water well report(attached to application). Depth `70 g, /
Q�Well capacity Test(attached to application) 7-5— Pm7 l.L.00gpd
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 h!19;1/gis.co.mason.wa.us/planninq 14 15_16_22_
Water use or limitation recorded................................... N/A Yes
Well Drilled -............................................................. Date N IagZ��
Individual Spring/Surfece Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source win 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 Commitirl Services Evaluation staff use only)
atisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
rater indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Cade,Title 6,Chapter 6.66.040-Determination of
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 to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: Date I I
This form may be scanned and available for public view at www.co.mason.wa.us.
Psic2 of2
SKOOKUM WELL DRILLING
_PUMP TEST FOR d2rfY f/efe Lei' HELL SITS Cmn1Y
NE_==GPM _LEVEL_ IME GPN LEVEL
ac
—_—.25- V
RECOVERY DATA:
_TIME$�L�LEVBL': ! TIM8 LEVEL IMS�'yQLEVBL,�_
_PUMP DATA: -- '
_NAP MODEL F/9 BO7-9rs/
_PUMP INTAKE A D�
_WELL DATA;
_SCREEN:_--_
_DEPTH:___
_STATIC WATER LEVEL:
_DATE WELL DRILLED:
_PUMP TEST PERFORMED aaY:
_PUMP TEST DATE:
Signature YW—
Printed From Mason County DMS
Pfinted firm Mason County DMS
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s ' RECEIVED
MAY 0 6 2024
. Alder Street
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