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HomeMy WebLinkAboutWAT2024-00283 - WAT Application - 7/22/2024 '. '� . ma MASON COUNTY WAT&_R�- M COMMUNITY DEVELOPMENT (�V�RpN PennkAUlcbnceQMen.Building.Planning SFellbli:(360)427-9670 and 400 8 6Besfai (360)2754467 ext 400 Elma'. (360)4�SE89L PV E D FAX(360)427-7787 CIIG Application for Determination of Water Adequacy JUL 2 2 2024 Instructions eet 1. Complete Part 1. No determination can be made until Part 1 is fully comol 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: '_ 1 t Dater P Mailing Adtlress: -A Vig N *j Phone: _7n(c) Parcel Number: Type of Water System Reason for Application p--� ❑ Public/Community Water System (2 or more t� Building permit &L'Q&Aaq-008I 0 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 welt, check the Public/Community,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: Water Facility Inventory(WFI)Number: (wife"none"for two-party) ❑ 1 am the manager of this water system.The water system has been approved for services. There are presently connections)in use.This will be the 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)connections)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 atwww.co.mason.wa.us. 1?EH FmmsA Dfi cing Wau k--d I '3,'018 Individual Water Well Water"if report(attached to application). Depth Z ✓-rt. Well capacity Test(attached to application) 1 apm—7-1-tOngpd. The well driller often performs yell 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 H 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 http�/tais.co.mason.wa.us/plaaa!M 14015[=160220 Water use or limitation recorded................................... N/A_=_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 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) ^E�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 vAh 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: Applicants 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 CSD Director: Date 2.f2 WATER WELL REPORT _=DEPARTMENT OE Naice vfNtmt No. WES7185 ECOLOGY Uvp Eoog WcgmTag No.BNM866 T.pe or W'o.R: state ofwani:gton Site Wdl Nmtn(iftoem thm ate Wd0: J cak o Occanmisnan �f Oribina:ivullation NOl No. Wtlm RigbtPmoitM,HtiSCtle N0. PtePmM Uea ■poeaoc 0Iu1mvW ❑Mmki l PtoppyOwon Nerve JESSICA H4LL AAN ❑OrwembR ❑Rcipaao ❑Tmwem ❑Omm Wdl Stress Address 101 BLACKSMITH DR Mew' city BELFAIR Camty MASON KNN—v Pl OAWawin ❑Diem ❑Rmtl ❑O Tw O Da l ❑t ❑Dm G Ah- ❑m.&R my Tex P 0 Na. 223037SM110 ph:eelwm: Dh .fb 6 b.m 2]3 R wmevedmceappmved fs this well'! 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