HomeMy WebLinkAboutWAT2024-00336 - WAT Application - 9/20/2024 d
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MASON COUNTY 415 W Street
SAelton,WA 98564
Public Health & Human Services SBelfair:360-2754467,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: Applicant/—Parcel Identification `
Name of Applicant: Je ht%_ tee za,vi l+�/ Date:
Mailing Address: %3Z F Al om QG Phone: 310-410-461C
Parcel Number: 321101 'SD-coor{Z
Type of Water System Reason for Application
Yl Public/Community Water System(2 or more jn Building permit lf�IQ _A021-1- 01 to
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 PublicJCommunity 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: ASOj.SA (write"none"for two-party)
o -lam the manager of this water system. The water system has been approved for _ services. There
are presently connection(s) in use. This will be the connection.
19 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.: recreatigqnnat to full timel. Please indicate on the following line the nature of
this change: AAr� o rn7 Ah,44/(�'rC�-l;an.J b f-11lk e_
This water system is able and willing to�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 Phone 7-A. 11 171T1
Signature of Water System Manager Date
This form may be scanned and aval(Ale for public view at www.masoncountywa.gov
MEH Forms\thinking Ware, Revised 05/082024 Pege 1 of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm gpd.
The well driller often performs well rapacity 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 within last year(attach to application).
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,Title 8, Chapter 6.66.040-Determi tion of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may al apler
36.70A RCW.
❑ Unsatisfactory Determination: A
Applicants water supply does not appear adequate to meet the needs of its intended use&Ohe foll"
reason(s). CQ ,rr��wer's Signatures: ! oy p igOg1p7y �O
Environ. Health: Revie Date
This form may be scanned and available for public view at www.masoncountvwa.aov
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