HomeMy WebLinkAboutWAT2024-00396 - WAT Application - 11/25/2024 WAT
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MASON COUNTY WA98584
COMMUNITY SERVICES Beltgn:360-427-96427-9670,Ext 400
Belfvc 360-27541467,Bxt 400
e„ia,naam�,yEmen,m.,,ui x..iro.c«�+,�nx.•rx Elora:360-482-5269,Ext 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is Tuliv cemoleted.
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. Ana roved buildingsite Ian must accom an this a lication.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Robert Stewart Date: November 25, 2024
Mailing Address 550 E Wood Lane Shelton Phone: (360) 549-6214
Parcel Number: 32021-56-02028
1
Type of Water System Reason for Application
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{� Public/Community Water System(2 or more q� Building permit r�c,r a,02`t -OH LF al
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 public/Community,Water signature required P n r�O V E D
System box. I—K
Part 2: Water Connection Information MASON COUNnEN�ROHQN O 4 2015
Complete the section appropriate for the type of water connection being evaluated: MENTAL HEALTH
Public Water System RET
Name of Water System:7Shor�reg Estates Water CompanyWater Facility Inventory ber: 78620-1 (write"none°for two-party)
❑ I am the manager of system.The water system has been approved for_services.There
J are presently connection(s)in use.This will be the connection.
�e I 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: Existing Connection-B ilding Permit
This water system is able and willing to provide water to this(these)connex%ion(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager
Knsde Hutchinson Phone (360)4260773
Signature of Water System Manager
Date November 25,2024
This form may be scanned and available for public view at www m mason.wa.us.
Revised 4f27a021
1:\EE Forms\nxiakiag Wamr
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gprn gpd
The well driller often performs well capacity tests at the time the well is constructed. Resu1perfoned
these tests are noted on the water well report. Results from these tests will be accepted. I
well report cannot be located by the applicant or if the water well report does not have a c
a well capacity test,which provides stabilization of draw-down and recovery data, must be
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://cis.co mason wa us/olannino 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes_
WellDrilled ............................................................... 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 B00 gallons per day;and/or
provides water 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)
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:
Applicants water supply does not appear adequate to meet the needs of Its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: ' ' r'/ Date
This form may be scanned and available for public view at www.ca_ mason Tray,
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