HomeMy WebLinkAboutWAT2024-00365 - WAT Application - 10/14/2024 �--
415 N.6e Strixt
Shetlan,WA e8584
12, MASON COUNTY Shebm.30-427A6711,Fxt.400
COMMUNITY SERVICES eltal3 nix 0-48L520,ext.4 0
uMng pyWyfryvwayFplhCwm�lhedn'
Application for Determination of Water Adequacy
Instructions
1, Complete Part 1. No determination can be made unfitsof waler conec oo utilized.
2, Complete only the portion of Part 2 applying to the type
3, Submit completed application,with any required enactments for review.
4 Ana roved buildin site Ian at a men Mis a licalfon.
Part 1: Applicanti Parcel Identification 10/14/2024
Name on Applicant: CHRISTOPHER WEEKS Date: 760-419-4550
1MaL 47H ST NW.IAKEBAY.VM 91049 Phone:
Meiling Address:
0028
Division-block-lot: 16-28
Parcel Number: 42216-53-0
Type of Water System Reason for Application
® Building permit
Ja PublidCommuniry Water System (2 or more ❑ Division of land:
connections) q of Parcels?— SPL
❑ Individual water source(one connection), ❑ Boundary line adjustment
❑ Well
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
of water system below if applicable-no
If you have mote than one residence connected signature required)
1,this well,check the Public/Community Water
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connecion being evaluated:
Public Water System
Name d Water System: I-AKE CUSHMAN SYSTEM 5
Water Facility inventory(WFI)Number: 035290 (write-none- twro-Party)
❑ I am the manager of this�nlnersystem.If^ In use.This will be the been approvedcoclot ro0�ervioes.There
are presently use ID I am the manager of this connection on this system Qa.m ectealional to This tlon full will
Please Indicate ode or n the foge llowingfl'me the nature re of
this change:
IThis water II—
limits of the water systemis able or any and willing
iil lin i a sal by state and local regulation
�nection(e)without exceeding e
Print Name of Water System Manager
JESSE MATHEWS Phone 360-877-2728
Signature of Water System Manager Cho hxtOaa=�S Date
This form may be scanned and available for public view at^^•^•'^ mason wa us.a ke 4a7MOI
11 Fn.A Drinking Weer
Individual Water well
❑ Water well report(soothed to application). Depth
ft.
❑ Well capacity Test(attached to application)
9pm gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results from
these testa are noted on the water well rei�t or if
Results he pted, if the water
water well report doad if the water
les notl be e e a capacity test,
well report cannot be located by the applicant
a well capacity test,which provides stabilization of draw-down and recovery data,must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Invento Area (WRIA)
=useOT
which WRIA _ - - a =Mlanri nc 14_16_16_22_
nrewrded..............................._.. N/q_Yes_....................................
Date
Individual Spring/Surface Water
rCll
permit to application)
d of disinfection
reason to believe that this water source can provide at least Boo gallons per day;and/ores water she
rate of 2 gallons per minute based on the following observations.
--------------
Date
Author of Statement
Relationship to Appllwrd
Part 3: Mason County Communlibif Services Evaluation staff use only)
LHSaMr
aetory Determination: f(be dishli,thch system.guarantee an adequate supply of
ndefi indefinitely
does note,Or guarantee
rantee oy compliance wiN all applicable WDOE water resource regulations.
mefinaelyinihefutureates rerentements ter B.6e040-Determination of
mended approval intliceles requirements of Sanitary Code,Title 6,Chapter Chapter
acy for Building Permits are satisfied. Additional Growth Management requirements mayapply. p
RCW.
tisfactory Determination:
ants water supply does not appear adequate to meet the needs of do IphlMed use for the following
(s).
Reviewer's Signatures:
lth:
Date
This form nay be scanned and available for public View at 7 MWALM aaaJl LU'- re,W2
Ito- nz><� Pa-V-S �l
Small: lmathews@lakacushmanmc.can
I'
r"2024-10-21
0-21 Application for Determination of
Adequacy 16-28 Weeks 2024-10-23
port
2024-10-21CtwvokeashmenSbned CdJCHBCMsAA0k313eZF4%HIF69V k IFaIBN014yc0-21 Application for Determination of Water Adequacy 1
6-28 Weeks" History
Document created by Chevon Brownell(cb(ownell@lakeGushmanm0.00m)
2024-10-21-5'.03',52 PM GMT
E: Document emalled to Jesse Mathews Qmathews@lakecushmanmc.com)for signature
2024-10-21-501:58 PM GMT
Email viewed by Jesse Mathews(jmathews@lakeoushmanm0.e0m)
2024-10-23-2:27:24 PM GMT
FYe Document e�signed by Jesse Mathews(jmathsws@lakecushmanmc.cum)
SIgnamre Dale:2024-10-23-2:29:24 PM GMT-TOO Bouma:server
Agreement completed.
2024-10-23-2P9:24 PM GMT
a Adobe Acrobat Sign