HomeMy WebLinkAboutWAT2024-0037 - WAT Application - 11/26/2024 415 N.6'*Street
MASON COUNTY Shelton.WA 98594
Shelton:360 427-9670,Fxt.400
Public Health & Human Services 136W. 3W2754467,La 40u
Application for Determination of Water Adequacy
Instructions is-
F4An
omplete Part 1. No determination can 5e made until Poftrcactionreutdifizadomplete only the portion of Pan 2 applying to the typeubmit completed application with any required attachments for revew.
a roved buildinQ site plan must accomp2ny this application.
Part 1: Applicant! Parcel`Id`en`tification i1 u0 �
Nam of Applicant �f]FN+ F'V �� Date:
V�cwh ZS3•TW' -W a�O
Mailing Address:
F1\ SI.OY 1 rJcA 1h�^�tione:
Parcel Number 23104-50-00045
Reason for Application
Type of Water System
Building permit
�oJ PublicJCommunity Water System(2 or rrrore ❑ Division of land:
connections)
R of Parcels?__ SPL
[I Individual water source(one connection), ❑ Boundary line adjustment
❑ Well
❑ Spnnglsunace water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
Of water system below if applicable-no
If you have more than one residence connected g
si nature required)
to this well,check the Public/Communify Water
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
FWaterater System: AIderbrOOkility Inventory(WP0 Number0t�B (wnte"none'fo:,fan
)e menager of this water system.The water system has been approvetl foerNcas. Theresently 540 connections)in use.This will be the 5 11 connectihe manager of Nis system.This connection will be to upgrade or change tan existingction on this system(i.e.: recreational to full time). Please indicate on the line the nature ofhange:ater system is able and willing to provide water to this(these)connectiot exceeding t e of the water system or any limits set by state and local regulation. 7-5249Brandy MAroyPhoPrint Name of Water System Manager Datr2024
Signature of Water System Manager Y
(? Il
This form may be scanned and available for public view at vnvar masoncauntvwa-Oov�I urz
Rerucd OStt1H/1O2d
1\Eii Fume\priokinB W mn
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
1bya
ll report(attached to application). Depth ft.
acity Test(attached to applicator) apm apd.
driller often performs well capacity tests at the time the well is constructed. Results from
ts are noted on the water well report Results from these tests will be accepted. If the water
rt cannot be located by the applicant or if the water well report does not have a capacity test,
pacity lest,which provides stabilil of draw-down and recovery data, must be performed
nsed contractor.
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Spring/Surface Water
FOM4ethod
rmit(attach to application)
f disinfectionason to believe mat this water source ran provide al least 800 gallons per day;and/orwater 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 suPPIY of
water indefinitely in the future,or guarantee compliance with all applicable WDDE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,ride 6,Chapter e.e8.Od0-Delemanall 01
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
38.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meat the creeds of its intended use for ins following
mason(s).
Reviewer's Signatures:
Environ. Health:
f�cl/� Date
This form may be scanned and available for public view at www masoncountvwa.eov
Pagc 2 mf2