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HomeMy WebLinkAboutWAT2024-00366 - WAT Application - 10/23/2024 WAT 2024-00366 MASON COUNTY 415 N.6 Street Shelton,WA 96584 Shelton:360-427-9670,Ext.400 Public Health & Human Services Eidfair:360-2754467,Ext.400 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 accom2any this application. Part 1: Applicant/ Parcel Identification Name of Applicant: Jason Campbell Date. 10/23/24 Mailing Address: 406 108th St S Tacoma WA 98444 Phone: 564-546-0742 Parcel Number: 223177590061 Type of Water System Reason for Application ❑ Public/Community Water System(2 or more 91 Building permit connections) ❑ Division of land: 19 Individual water source (one connection), #of Parcels? SPL 91 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) ❑ 1 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. Print Name of Water System Manager Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.masoncountywa.gov I TH Forms\pdnhng Waar Revised 05/Og2024 Paee 142 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well * Water well report(attached to application). Depth 204 ft. Well capacity Test(attached to application) 16 gpm >400 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 well report cannot be located by the applicant or if 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. IA Satisfactory bacteriological test within last year(attach to application). Submitted to lab 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) X 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-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 36.70A RCW. Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Environ. Health: Reviewer's Signatures: Yb�' Date 11/22/2024 This form may be scanned and available for public view at www.masoncountywa.mov, Page 2 of 2 WATER WELL REPORT DEPARTMENT Or Notice of loMot No. WE67M ECOLOGY Udqu E obg W mTag Na. BNMSB) lT}erwM: stare of wxNPWon � Cmommo sire WNI Na>s(irmme M®aoe weN: ❑ N[ammmm q GrMrmladdNuw NOI No. Wuer Right PermiVCertificare Na. P"Pp lNn aDasmac ❑lw.w ❑Mm.'a Property Owoer Nerve FUTHUR HOMES Cl D—.m ❑kIW. 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