HomeMy WebLinkAboutWAT2024-00332 - WAT Application - 9/11/2024 WAT
415 N.61°Street
MASON COUNTY Shelton,WA 98584
Shelton:360- 6 ,Ext.400
COMMUNITY SERVICES
Belf.ic 360-2]5-042754467,Ext.400
a,uny rm,��sri..:a,mMui xWMcammw�ryxedtl Elm.:360482-5269,Ext.400
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. Ana roved buildingsite Ian must accompany this application.
Part 1: Applicantl Parcel Identification
Name on Applicant 'n A mra_��o Date: �Q I11 I7 u
Mailing Address: � 1 ct gLACIA P�2geao Phone: 360- 6 '�9y
Parcel Number. 32232-50-12001
Type of Water System Reason for Application
Public/Community Water System(2 or more Building permit �tJid?vZ�! D II77
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
If you have more than one residence connected of water system below if applicable—no
to this well, check the Public/CommunHy 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: Union
Water Facility Inventory (WFI) Number: 51920 W (write"none"for two-party)
I am the manager of this water system.The water system has been approved for 316 services.There
are presently 263 connection(s) in use. This will be the 264 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 set by state and local regulation.
Print Name of Water System Manager Brandy Milroy Phone 360-877-5249
Signature of Water System Manager Date 07/10/2024
This form may be scanned and available for public view at www,co.mason.wa.us.
19EH Forms\Drinking Warer Revised 42]2021
Individual Water Well
❑ Water well report(attached to application). Depth R.
❑ Well capacity Test(attached to application) apm 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 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 htto 1/gis.co.mason.wa.us/planning 14= 150 18=22=
Water use or limitation recorded................................... N/AJZI_Yes=
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I 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)
FR�drnmendedl
tisfactory Determination:
s determination does not address adequacy of the distribution system,guarantee an adeQr ly of
er indefinitely in the future,or guarantee compliance with all applicable WDOE water re5oa re S.
approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Dete in
equacy for Building Permits are satisfied. Additional Growth Management requirWents may gpoly. t
70A RCW.satisfactory Determination:
plicant's water supply does not appear adequate to meet the needs of its intended usefor t�4.1�1��son(s). O✓4
ON1jFNTA�yF4
Reviewer's Signatures: (T
Environ. Health: Date
2 are
CSD Director: Date