HomeMy WebLinkAboutWAT2024-00214 - WAT Application - 5/3/2024 WAT,2W Y ' i—
MASON COUNTY
COMMUNITY DEVELOPMENT
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415 N S'^Street,Bldg 8,Shelton WA 98594,
Shelton:(360)427-9670 ext 400 O Belf360) 5- 787 7 7 �400 O Elms:(380)482-5269 sid 400
FAX
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 1 entification
Name on Applicant: Od J Date: _ ?i
11
Mailing Address: !• Phone: 360- 22e -02. Sr.
Parcel Number: L -L L I to--S7-^0612— 1 Division 10 Lot 121
Type of Water System rAAka737 ;,,, Reason for�Application /e
❑ Public/Community Water System (2 or more X Building
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdngisurface 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 i
to this wefl, check the Pubfic/Communfty 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: TAKE!`1TCLIMAN cvcn-cM5
Water Facility Inventory(WFI)Number: mt;990
(write"none for two-party)
❑ 1 am the manager of this water system.The water system has been approved7ane)(IsUng
.
There are presently connection(s)In use.This will be the
I am the manager of this system.This connection will be to upgrade or changingconnection on this system (i.e.: recreational to full time). Please Indicate on thnature
of this change: Rebuildino new residence
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.
.7Ptt_ A4i�th2W( _ 05/08/24
Signature of Water System Manager.�...,�..w."a.>o� �a==>on Date
This form may be scanned and available for public view at W .ca.mason.wa.us.
Rwiscd ll2L2P18
1:\EI3 Poms\Drmkin6 Water
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) opm 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,flcis.co.mason.wa.uslolanning 14[Z3 1bD 16M22[D
Water use or limitation recorded................................... NIAJZ::LYesQ
Well Drilled ............................................................... 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 staff use only)
�Oatisfactory Determination:
lThis 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. -
❑ 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: Q " ' y Date.
CSD Director:
Date 2 efz