HomeMy WebLinkAboutWAT Application - 10/23/2024 MASON COUNT WAT Exs�i
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COMMUNITY SERVICES Qo f+to
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415 N 6' Street,Bldg 6,Shelton WA 98684,
Shelton:(360)427-9670 ex[400 O Belfair.(360)2754467 ext 400 O Elm:(360)4825269 ext 400
FAX(360)427-7787
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 on Applicant:Wlnlir__. &rL ErAG Date: Ib Wl
Mailing Address: IpX_�N eh;A�t Dr. &K 200 Phone: &-5'&-3b93
Parcel Number. 32-X33-S6"b090J -q.15-1573-1156
Type of Water System Reason for Application I
❑ Public/Community Water System(2 or more X Building permit B�a.024-OI20
connections) ❑ Division of land:
0 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.
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:
(write"none'for two-party)
❑ I 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.
❑ 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:
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 Dale
This form may be scanned and available for public view at wwrw.co.mason.vm.us.
t.NEKF Wnnkiosw� Revised I," MIS
Individual Water Well
❑ Water well report(attached to application). Depth fl.
❑ Well capacity Test(attached to application) oprn gpd.
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 report does not have a capacity test,
a well rapacity test,which provides stabilisation 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'jigis.co.mason.wa.us/planning 14=150 160 22=
Water use or limitation recorded................................... N/Aj=Yeses
Well Drilled ............................................................... Date
Individual Spring/Surface Water
rmit(attach to application)
isinfection
on to believe that this water source can provide at least 800 gallons per day; antllorater 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)
FRemmmended
atisfactory Determination: guarantee an adequate supply d
is determination does not address adequacy of the distribution system.
ater indefinitely in the future,or guarantee compliance with all applicable W DOE water resource reguletiorc.
approval indicates requirements of Sanitary Code,Title 6.Chapter 6.68.040-Determination of
dequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
6.70A RCW.nsatisfactory Determination:pplicants water supply does not appear adequate to meet the needs of its intended use for the followingason(s).
�(Reviewer's Signatures:
Environ. Health: �Y✓ 1 Date
]oft
CSD Director. Date