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HomeMy WebLinkAboutWAT2024-00314 - WAT Application - 3/25/2024 WAT L Q03L4 415 N.61°Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:360-427-9670,Ext 400 aelfair:360-275-4467,Ext.400 EUAdng Vlsnig E,M,mmoxal xeddtcanmunlry HeYtl, Elma:360-482-5269,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. An approved building site plan must accompany this application. Part 1: Appllcantl Parcel Identification Name on Applicant DAVID SfaKES Date: 3125�?V14- MailingAddrew: SEJ)N 'dI6S5GyV&n&"hone: p 0-9171 Parcel Number: 2202b A 90011 Type of Water System Reason for Application PublidCommunity Water System (2 or more Building permit aLD cQ4-01033 connections) WELaDAq-000� Division of land: ❑ Individual water source (one connection), Elon), #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 PublialCommunity Water signature required) System box. Part 2: Water Connection Information ° P` wut aoaKi Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: .2-fAkTV WELL Water Facility Inventory(WFI)Number: ND�E (write"none"for two-party) I I am the manager of this water system.The water system has been approved for 2 services. There are presently—f(_connection(s)in use.This will be the ZNc 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 w ter to this (these)connection(s)without exceeding the limits of the water system or any limits set by tale and local regulation. r ��f Signature of Water System Manager Date `3.l✓ hY- This form may be scanned and available for public view at t4tww.co.mason•wa.us. l:\ Forma\Drinking Water Revised 4/4/2018 Individual Water Well Water well report(attached to application). Depth r�,I pf Well capacity Test(attached to application) eb 0 gpm 7 1 ©0 apd. TTTThe 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://ais.co.mason.wa.uslolannine 14 x 15_16_22_ Water use or limitation recorded................................... N/A Yress_ ti Well Drilled ............................................................... Date b t J 7 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) 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,Tile 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: Applicants water supply does not appear adequate to meet the needs of its intended use for the following mason(s). np Reviewer's Signatures: Environ. Health: �`/' ' "' ' 1 , Date This form may be scanned and available for public view at www.co.mason.wa.us. 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