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HomeMy WebLinkAboutWAT2021-00337 - WAT Application - 2/13/2024 . WAT 2D21 - OD3�2"1 SEE AITRCA-ED 415 N.O Stmet MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Belba:360-2754467,Ext 400 aelfeir:360-275J467,Ext.400 a,u,,,am.��me.e,„�„n,nmmixmim.commu��n xme, Eime:360-482-5269,Ext 400 Appiication 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 Applicant: Mattson Land Consulting, LLC Data: 02/13/2024 Mailing Address: 21987 Wh Ave F Graham, WA 98330 Phone: 263-228-7462 Parcel Number: 422046000087 Division-block-lot: 5-87 Type of Water System Reason for Application jO Public/Community Water System (2 or more © Building permit &LD7-07/1-00 5 745 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 (please indicate name N you have more than one residence connected of water system below if applicable-no to this well, check the PuhlirlCommunity 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-party) ❑ 1 am the manager of this water system.The water system has been approved for-'/ ices.There are presently connection(s)in use. This will be the connection. Ell I am the man:�,.atiunal r of this system.This connection will be to upgrade or change the use of an existing connection ois system(i.e.: recreational to full time). Please indicate on the following line the nature of [E ihischange: to full time 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 JESSE MATHEWS Phone 360-877.9668 Signature of Water System Manage ..w.,r....--M Date 02/1412024 This form may be scanned and available for public view at www co rrtason.wa-us. Revised G27I2021 1:TH Forms\Drieldn8 water RECEI�EL MASON COUNTY } 2 COMMUNITY SERVICES, ,,r 3202, ay4[4p�riirxwY}.tlM14dl1�NMJn HwY'1hf.rtm.M`il H.� ,`, 415 N 6%Street,Bkl9 a,Station WA 905a4. Shelton.1360)427-9970 ert 400 0 8011 i(3aoi vi +;fi7 cxt4o0 O Etna:(3601 4 92-5269 W 400 FAX �MlQT-7787 Application for Determination of Adequacy &Z+ _W753-7 Instructions t. Complete Part I. ,No�tennnarw+can ba made until PaA f isr sy ern ut tad tAI 21 Complete only the portion of Part 2 applying to ate type of water system utkmd. 0. Submit COM Laced RMiCabort,w#h attachments to the heabn de meni for rswew. /Email: ftulkarwnOWmsr.com --- 3� ' of Part 1: Applicant/ Parcel identification 4 4/ T,44 Name on Applcant. Tom F.. Fulkersdo Dsta: 7.2t•2021 Maerp Address' ag5.10611 St S Tawas We g54" __Phone: 2532306366. _ Parcel Number 422915000067 __._. r_ , ___Drirision& Lot: 5.87 Type of Water System Reason for Application IK pualiclCom,,,Ity Water System(2 or nwre X. Buffing perrrxt ranneutiona} :-p oivision of land: '3 Individual wafer source lone connection). _ #of Parcels? SPL to Wes 0 Bountlary line adjustment El SpringAurface water •.0 Crow (enplamj 10 ottter(expiasn}1, (®' {taptammerd(please nocate name of water it you have mora fhan orb residence connaded systems below 4 applicable-no SiV2turo 10 fts tree', check the PuWiG'COmmundy Water required) System box. '7 YLYM 'f9N' Part 2: Water System Information ~ Complete the section appropxiato for tha type of water system being eYakias ti Public Water S stem r___ me W Water systam: i.am custunan System 5 er Facility Inventory (WFI)Number 03529 0 (wnte'none for two-party) unspecified 1 am the manager of this water system Tiro waxer system has been approved forasThere are Presently 1567 connections) in use.Thin will be the NxWnnaC40n. I am the manager of this system. This connection w411 be to upgrade o change the use bf m axisting connecnion on this system(i.e.:reer"ootial to hA time).Pteau indicate on the foNartmg line the nature of this cl,anga_ Tna water system is abase and willing w WOV40 water to this (thase)cennac"sj waho t exceeding the limns of the water system or any limits set by state and local regulation, PnM Name of Water System Manager Rar+dy Brtre Phony 960-677-gM rr,.,r,4 r Spnaaure of Water System Mansger � Date 0 7 12 1,20 21 _ This form maybe scanned and i �Mic view on the Hawn County Web site. Individual Water WON G Water well report(attached to appl"te)n). Depth It. D Wey capacty Test (attached to application), gpm 9pd- The wall driller often peiorms well Capacrty tests at ire time the well is constructed. Resutis from these tests are neled on the water well report. Results from these testa wa be Wcepled. II the water well report cannot be iocated oy the appecart or e the water we"report does rate have a Capacity test a wall capacity test, which proveles stabilization of draw-down and reariery data, must be performed by a licensed Contractor. 0 Sattsfacloty bscteriologcal test iatlach to applicaWrit Individual Spring/Surface Water D WDOE permit(attain to app4ica5on) 0 Method of disinfection D I nave reason to beeeve that this weer source can provide at least$W gallons per day:anNor prv✓ides water at a rate of 2 gallons per minule based on the following observations, Auq+or o1 Statement Date Retabonship to Appl,cant Departmental Use Only: Do not write below this line. Part 3: Mason County Public Health Evaluation Satisfactory Determination: A{r,>iK..inrs wafer suGdy d< appear»dequ»te to meet rrw nec a ns inisn' v o, Thb does rot eddroes >uaauar.Y of the d.sinlow.on syuem.yuanre"en edWp"supply et wafer i ,jefina r,n ace futwe,or guarantee Cornpliance win ail amptiraaw WDOE Meter raedume r"q,"t,om. Reccmmended aPPMEWAl n6caMs nque`l nb of:aNtM Coda.Tom a.OMpM 8.66.r}Fp..Oelemunahon of Adequacy tw au" Pr its are say fled. Addbof+at Groedr Manapwerrt regaaomdtta n'rai'apriy. C sew 3a.F9A RCW. "- Unsatisfactory DetermNation: au AppscanCs water OplY does not appear sAograte b meal the nook all as intended u se row the.. FDllowiriq r»aacngs). Reviewer's Signature: '-r ' y r"J Date __-- ftn,sG 414:Mi:l F+En Fanny.Llnnlnu Wafer f`aie This form may be scanned and avaiiable for public view on Lire Mason County Web site• Printed r ,