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Home My WebLink AboutWAT2024-00317 - WAT Application - 9/5/2024 WAT 202 boater—� l� 4I5 N.61°Street MASON COUNTY RECEIVEL6heam W'A 98584 COMMUNITY SERVICES Shelton:360427-%70,Ext.400 SEP 0 360-2754467,En.400 _Zg,vw„1ry tmxo Q-1 H. Ith comm��Nr�wm 360-082-5269,E#.400 Application for Determination of WAP Al#" 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 accom an this a lication. Part 1: Applicant/ Parcel Identification Tr Nameon Applicant: V�pr'4✓trill �PfWl q il��..!✓Date: lohIZq Mailing Address: 7iy n'1 A4'� � �O�Phone: � _�� Lf76 7 Parcel Number: 22024-75- 46043 5l`Gfich/kro}185$�( Type of Water System Reason for Application l6"'Public/Community Water System (2 or more 9/'Building permit 6L OZ-o2-f- Ot o%o 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/Community,Water signature required) System box. ,r coonac iw1 O✓9 Part2: Water Connection Information 1 '•� Pavlr-) OeLu7J+D0o�� Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: 410 - I60 b CLIN L✓ LV ck $yf4e Water Facility Inventory(WFI)Number. No Nf (write"none"for two-party) lam the manager of this water system. The water system has been approved for 2. services. There are presently 0 connection(s)in use. This will be the 1 sr cor rce ion. ❑ 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. Signature of Water System Manager Date This form may be scanned and available for public view at 1pplp86S00.w11.Yt• JMH F.A DtiWk Wet- Revised 4/4/2018 Individual Water Well Cr)` Water well report(attached to application). Depth 3V fL ❑�Well capacity Test(attached to application) 23 gpm?L 9pd. 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 V 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. [3 Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA htto!/ois co mason wa uslolanninc 14_15_16_22_ Water use or limitation recorded................................... WA Yes_ 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 600 gallons per day; andlor 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) j 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 win 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). �Q � Reviewer's Signatures: Environ. Heatth.K- �tq-y\WI'r��t qm Date 10 712i j This form may be scanned and available for public view at MnVW co eas:. wa=. Pxpe 2 of 2 WATER WELL REPORT DEPAR'. O Or w,.- m NP iDT. ] — ECOLOGY u:,"®mr■•wamT>allo- eraw5w T11•d wvn: 1:am oC u'a.emgenn �y t wounm ses w.B N.z LammeBm�me menr. a fl tt.cmemmo (Aipml mm4Gw NOt Na _ Waver Ri3hl peruvT'eeifirr.Nw Irepeee.lXe: A0.6r. :1:Nmr1 .'J M.rttp1 Neyet7 Omwr Wow LAMES PYLE C Dorr.a.N u0ei ❑Tm WN [:(Ner.-. 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