HomeMy WebLinkAboutWAT2024-00368 - WAT Application - 11/4/2024 ENVIRONMENTAL
HEALTH
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MASON COUNTY Shelton,
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Application for Determination of Water Adequac Street
,5 �N. Alder
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 a2proved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name of Applicant: LAKE, PATTY Dom: 10/28/2024
Mailing Address: PO BOX 2121 BELFAIR WA 98528 Phone: 360-801-1570
Parcel Number: 22127-52-00056 _
Type of Water System Reason for Application
Public/Community Water System(2 or more VnJ Building permd
connections) ❑ Division of land:
❑ Individual water source(one connection), N 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 orm residence connected of water system below if applicable-no
to this well, check the Public/Communify 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: RUSTLEWIDOD
Water Facility Inventory(WFI)Number: (write°none'for Marty)
❑ 1 am the manager of this water system.The water system has been approved for_services.There
are presentlyconnection(s)in use.This will be the connection.
I 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: Replace modular home
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.
Print Name of Water System Manager Richard Dickinson
� Phone 10/28/2024
Signature of Water System Manager /� -, - �
This form may be scanned and avallabia for public view at www.law"countvwaaw
/:1EH Forms\Drinking Wwr R.i d0SIDIG T4 PW 102
Group B Water Systems
❑ Saasfactc ry bacteriological test within last year(attach to application). _. .....
Individual Water Well
❑ Water well report(attached to application). Depth a.
❑ Well capacity Test(attached to application) gpm gptl.
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 raper(does not have a capacity test,
a well capacity lest,which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological lest 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 6,Chapter 6.88.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
LI Unsatisfactory Determination:
Applicanre water supply does not appear adequate to meet lire needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health `� Date
This form may be scanned and available for public view at www.masoncountvwa.aov
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