HomeMy WebLinkAboutWAT Application - 9/1/2024 MASON COUNTY WATI
COMMUNITY DEVELOPMENT
r fttMummec W,,guildiM arming
415 N 6-Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ex[400 4 Belfair.(360)275-4467 ext 400 4 Elm:(360)482-5269 ext 400
FAX(360)427-7787
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 accompany this application.
Part 1: Applicant/`Parcel
Identification '
Name on Applicant) -4mr&AUiA� Date: 5-47- ��
Mailing Address: �� EV`�IRYVIYDGt_l>. Phone: aOLP • 67b • '-7 5Z
Parcel Number: 3212'1-Sax-LWA) ), 5haAm-- WA q856
Type of Water System Reason for Application
AKPublic/Community Water System (2 or more Id Building permit f-�Id 2OZ2 •6107
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ 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 PubliclCommunity 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: ,La i w i . Uri
Water Facility Inventory(WFI) Number:
(wnte"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 (Le.: recreational to full lime). 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 Date
This form may be scanned and available for public view at www.co.mason.wa.us.
1:\EH Foam\Drinking Wno Revised 11352018
Individual Water Well
❑ Water well report(attached to application). Depth
ft.
application)
gpm gpd.
❑ Well capacity Test(attached to app'
The well driller often performs well capacity tests at the time the well is constructed. Results from
city test
these tests are noted on the water well report. Results from these tests will be accepted. If the water
er 1
awell report cannot well capacity tes capacity test,
t which provides stabilization of draw-de located by the applicant or if the own
a cap
nd report does
data, muave ave st performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
111 Development within which WRIA htto//Qis co mason wa uslolanninq 14�15�16�220
Water use or limitation recorded..........................
N/A Vest
Well Drilled ...............................................................
Date
Individual Spring.Surface Water
rermit(attach to application)
f disinfection
ason to believe that this water source can provide at least 800 gallons per day; and/or
water at a rate of 2 gallons per minute based on the following observations.
Dale
Author of Statement
Relationship to Applicant
Part 3: Mason County Cgfuture,or
mmunity Services Evaluation (staff use only)
❑ Satisfactory Deon: n system,guarantee an adequate supply of
This determination ddreua nleeacompliance with allcy of the applicableWDOE water resource regulations.
water indefinitely in r gSanitary ion ter
ARecommended dequacy fo Buidiare rsatisfied.Additi nal Growth-tidManagem ntarequirement�aytapplyation F36.70A RCW.❑ Unsatisfactoryation:Applicanrs water snot appear adequate to meet Me needs of its intended use for the following
reason(s).
n Reviewer's Signatures:
Date�—
Emdron. Health: •+v 2of2
Date�
CSD Director: