HomeMy WebLinkAboutWAT2024-00309 - WAT Application - 8/15/2024 r '
ENVIRONMENTAL WAT aba. - _
HEALTH RECEIVED
415 N.6'°StmN
MASON COUNTY Shehm WA 98584
COMMUNITY SERVICES AUG 15 2024 Shchm:360427-9670,Ext.400
( aclfmr:360-275-4467,Ext.400
B"Id,Pia1111e,Ew and x.i,h.mMMIIIro Hs ffi 015 W. Alder Street Elm.360-482-5269,Ext.400
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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
Nameon Applicant. \DAW WoVa>rM1?1 Date: `I.3-2.0.2 }
Mailing Address: 9-6I N.IiaA All�oh Phone: 360•140•0345
Parcel Number: lol'I• 5o�tnp -
Type of Water System Reason for Application
Ed Public/Community Water System (2 or more Ili/ Building permit a��aoay-01�7
connections) "WiN ¢61 W Q11 ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdnglsurfam 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 Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water contraction being evaluated:
Public Water System WIFU\ GZY -00 `I L
Name of Water System: , "xrtd WQII (WRIT IDrA•ttA On led-
Water Facility Inventory(WFI)Number: yloyie
(mite-none-for two-party)
311/ 1 am the manager of this water system.The water system has been ap roved for-2—services.
There are presently_ I 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 (i.e.: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 s by state an local regulation.
Signature of Water System Manager Date
This form may be scanned and available for p tic view atwww.co.msisonwa.us
]?EH F.\Prmlin6 Watc, Re iud 4/4/2018
Individual Water Well
`❑,Water well report(attached to application). Depth ft.
It Well capacity Test(attached to application) pin gpd.
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 stabiliution of draw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
)t Water Resource Inventory Area (WRIA)
Development RIAhtto://cis.co.mason.wa.us/olannina 14_15_18_22_
Water use or limitation recorded................................. N/A Yes_
Well Drilled ............................................................... Date
Individual Spring/Surface Water
❑ W DOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe 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 only)
:y 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 W DOE water resol®ulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.( - lion of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may p apter
36.70A RCW. y
G Unsatisfactory Determination: qs4,r
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Applicants water supply does not appear adequate to most the needs of its intended u theTdl"ng
reawn(s).
9n,Fy�p 101y O
Reviewer's Signatures: ✓4 'yFyT
Environ. Health: Date C
This form may be scanned and available for public view at www.co.mason.wa.us.
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