HomeMy WebLinkAboutWAT2021-00277 - WAT Application - 6/22/2021 RECEIVED
ENVIRONMENTAL JUN 22 2021
HEALTH c ii VV. Alder Street
WAT ( _ jt�
MASON COUNTY 415 N.611 Seal
Shcltm.WA 98594
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Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No delerminathn can be made until Pad 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: UX,Date; lo�Iq I AAa.
Mailing Address: 5 O -67.n aec
Parcel Number: ln,%n 50-SO-r»p u.i'1%
Type of Water System Reason for Application
�(Publlc/Community Water System(2 or more KBuilding parmit-[[bad at^dOQb$
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well❑ Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) L❑ Olh lain)
y3 Replacemen r Remodel(please Indicate name
If you have more then one residence connected I'� water system below if applicable—no
to this well,check the PubliclCommunify 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: CJ
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.
I I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on thlryst4r(i.e.: recreallonal to full time). Please Indicate on the following line the nature
of this change: 1 C A n C�tnCl mrr n l)-F Ylr X)D P
This water system Is hble and willinb to provide water to this(these)connection(s)without exceeding
the limits of the water system or any If It set b it and local regulation.
Signature of Water System Manager Date ,gG Zy21
This form may be scanned and available for public view at www.co.mason.wa.us.
JVH Fmms1 Dmldng Wmer R-4M NnOl8
Individual Water Well
❑ Waterwell report(attached to application). Depth p,
❑ Well capacity Test(attached to application)_ pm opd
The well drit er often performs well capacity lasts 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. It 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 lest, which provides stabilization or 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 WRIAhllg:/Lqis.co.niasgn.wa.Lis/planDLng 14_,15_16_22_
Water use or limitation recorded................................... NIA_Yea—
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE 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 sfaff use on!
* 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 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
U 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
This form may be scanned and available for public view at Wwv,.co.ma5cmwa.us.
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