Loading...
HomeMy WebLinkAboutWAT2024-00333 - WAT Application - 7/30/2024 WAT 2024.00333 MASON COUNTY Shetwn,ho W Strmt WA 9SSS4 Sh.h.:360427-9670.110.400. Public Health & Human Services Btlfdr.360.2754467.Bxt4o0 ' Application for Determination of Water Adequacy Instructions 1. Complete Part 1. No determination can be made until Part i is fully cdmbleted. er 4tM;uNlized 2. Complete only.the�rortion of part 2 a IY196 to the�of wat mic ., '� � 3. Submit completed apprication with ari requlfeA¢�ktadamsn�a'(o - 4. An approved buildinll site Ian must accom-a this a Idetlon: Part 1: Applicant/ Parcel Identification --•� I/ �, / ` a Name on Applicant: Date: Melling Address:(e Phone:Q1 Parcel Numbor��} t�cvc Fl y r Type of Water System Reason for Application PubliclCommundy Water System(2 or more Building permit connections) ❑ Division of land: ❑ Individual water source(one connection). #of Percale?_ SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name Nyou have more than one residence connected of water system below If applicable—no to this well, check the PubliclCommunNy,Water signature required) System box. Part 2: Water Connection information EH APPROVED Complete the section appropriate for the type of water connection being evalua Rhonda Thompson 10116/2024 Public Water System Name of Water System: 4Vna.4, ' N Water Facility Inventory(WFI)Number. 0`63� (write'none'for two-parry) M am the manag�rr ff this water system.The water system has Qean,,approved foreservices.There are pros enlly y.S t] connection(s)in use.This will be the yS"I connection. ❑ 1 am the manager of this system.This connection will be to upgrade or change the u69 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 provlde water to this(these)connection(s)without exceeding the limits of the water system or any limb set by state a d I el regulation. Print Name of Water System Manager dR.a� lr Phone/?(G78 Signature of Water System Manager lIZr. Data 7_1— This form may be scanned and available for public view at www•masencountvwaidw l:tEH ipwc\DnNung Wear acis dWlnom pw t d2 Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) upm Qpd' 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 t or If he er well report a wwellell ccapacity les cannot t which provides Stabilited by the zation oftdraw-down and recovery dataoes not, must be pave a capacity t9st erformed by a licensed contractor ❑ Safi factory bacteriological test(attach to application). Individual Spring/Surface Water 7reason ttach to application) ection believe that thls water source can provide at least 800 gallons per day;andfor at a rate of 2 gallons per minute based on the following observations. Author of Statement Data Relationship to Applicant — — Part 3: Mason County Community Services Evaluation (staff use only) - ��-,w «+� opal t k d',51yI rpH e 4 Snmr{ [ivJie`iS 4Y° �_ Z. lif� x� This teem is"ba scanned and available for public view at www maeoneountvwa.gov Page2of'e.