HomeMy WebLinkAboutWAT2024-00367 - WAT Application - 11/4/2024 MASON COUNTY WATT- 00
COMMUNITY DEVELOPMENT
Peemn Md..h ..Building.lslmniry
415 N 6t'Street Bldg 8,Shelton WA 98584.
Shelton:(360)427-9670 ext 400 4 Belfair:(360)275407 ext 400 6 Elma:1360)482-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No detemiination 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 accom2any this applicatiodr.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Todd Hinders Date: 11/4/24
Mailing Address: 71 E Happy Home Dr Belfair WA Phone: 360-620-1738 _
Parcel Number: 22223-76-00130
Type of Water System Reason for Application
❑ PublirJCommunily Water System(2 or more lf Building permh -60;t oa4 '0/311/
connections) ❑ Division of land:
El Individual water source(one connection), #of Parcels? SPL
El Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel (please indicate name
If you have more than ogre 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
(write"none"for two-party)
❑ I am 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.
❑ 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)connection(s)without exceeding
the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Data 11/4/24
This form may be scanned and available for public view at ww ca mason wa us.
]1EH F.11 Dnnking Wm<, Revised 12512018
Individual Water Well
El Water well report(attached to application). Depth 267 ft.
El Well capacity Test(attached to application) 10 gpm 7 "I C20 god.
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 0 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.
El Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area(WRIA)
Development within which WRIA http Ygis.co.masonma.us/plartaing 14=16=160 220
Water use or limitation recorded................................... N/AQ Yeses
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)
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 6.68,040-Determinallon of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36,70A RCW.
G Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
mason(s).
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