HomeMy WebLinkAboutWAT2024-00150 - WAT Application - 6/18/2024 WAT _ QQ
MASON COUNTY She4lton,Shelton.
Street
WA 98584
Shelton:360427-%70,Ext.400
Public Health & Human Services Belfair:360-2754467,Ext.400
Application for Determination of Water Adequacy
r
ructions
Complete Part 1. No determination can be made until Part 1 is fully completed.
Complete only the portion of Part 2 applying to the type of water connection utilized.
Submit completed application with any required attachments for review.
Ana roved buildin site Ian must accompany this a lication.
Part t: Applicant/ Parcel Identification
Name of Applicant: YV�,Ot+ Date: ���7
Mailing Address: Phone: Jir.C� 'r, 4U
Parcel Number: 7;Z, 53—S7-"
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more Building permit gLt-Z02��36 O
connections) ❑ Division of land:
individual water source(one connection), #of Parcels? SPL
K Well ❑ 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 if applicable—no
to this well, check the PubliclCommunity Wafer 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)
❑ 1 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(Le.: 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)wnnection(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.masoncountywa.goy
1'\EH Forme\Oinking Water
Revised 05/08/2024 Page 1 of2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
Water well report(attached to application). Depth UYl'�-4l rz�._�R. r
Well capacity Test(attached to application) I 71. o ��The well driller often performs well capacity tests at the time the well is constsults I
these tests are noted on the water well report. Results from these tests will be accepted. If thwell report cannot be located by the applicant or if the water well report does not have a capaa well rapacity test, which provides stabilization of draw-down and recovery data, must be pe
C /by a licensed contractor.
1 Satisfactory bacteriological test within last year(attach to application).
' \ Individual Spring/Surface Water
FE permit(attach to application)d of disinfection reason to believe that this water source can provide at least 800 gallons per day;and/or
es 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 only)
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 6.66.040-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: ��r✓ I Date
This form may be scanned and available for public view at www.masoncoun�aaov
Page 2 ol'2
COOLWATER DRILLING, INC.
10921 HOLLY RD NW
BREMERTON, WA 98312
360-830-9005
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CUSTOMER NAME DATE 5-28-24
JOE MOTT
CUSTOMER ADDRESS
250 E OSPREY LN
TIME STATIC GPM TIME STATIC GPM
46 15
OS 46 15 120
10 46 15 135
15 46 15 150
20 46 15 165
25 46 15 I80
30 46 15 205
45 46 15 220
60 46 15 235
75 46 15
90 46 15
105 46 15
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TITLE NOTIFICATION OF WATE4 CE INVENTORY AREA (WRIA)
I(We),the utdersigrad.11erely'Place this notice on record that the fnlb\dng dcaxibod red estate sinuaed'"Wants
County.Swe of washingtu¢to toil:
OR 2
Subdivision Division Range Toonship Section
IuNharing lheTaz Parcel Nu P. 3 3 -- .f_G -- d Lnl
b sobjewt to voter an res oils d cendRlans set by Waddngtao State Senate 0016991 Rod Mason
Couroty Code 6.6R. res nl conditions are based on Walton o(proplrty suadlor Wata•
Resource Inventor res or WRIA: maslmnm Annual Averuge(;nllans Per Day: ISO
Doted or ,2009—.
Signaonc Signature
o hingum )
Can.. ) of Mason /
the undersigned,a Notary Public in and far the above named Counl)'and SINc,da Mmby cenify IhW on this
�'14 do)of .)y�rp,Q�/A�� 201j—, 1 Perommll)•appeared
before non,who is knoen to by me signer of the abo a in9rumeM,and u knowledged that he(-he)(luoy)signed il.
\\\\� <iiren,wider nD.hand and officialseal the de)'mid year last above mitten.cn. —
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