HomeMy WebLinkAboutWAT2025-00005 - WAT Application - 1/15/2025 WATI — 0000
DECEIVED 415N.6a'Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES BAN 15 2025 SheftBelfar:360-275.4467,Exi 400
eanarselmmy.Emirwma ml HW&Co rvmnlgHealM � JJ. Alder StreetIrna:360-482-5269,Ext.400
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Application for Determination of Water Ad RONMENTAL
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: Santa Rita Builders Date: 12/16/2024
P .. Ua^ (360) 789-1365
Mailing Address: nm,aa wxmwe Phone:
Parcel Number: 42216-53-00116 Division-block-lot: 16-116
Type of Water System Reason for Application G
X Public/Community Water System(2 or more ® Building permit P) rL,/�9-baJC ODV5
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,Wafer signature required)
System box.
Signature ,,, amIIM 1oK.s.�ar�m.1
Part2: Water Connection Information Email Address villinesdirtwork@gmail.com
Complete the section appropriate for the type of water Connection being evaluated:
Public Water System
Name of water System: LAKE CUSHMAN SYSTEM 5
Water Facility Inventory(WFI) Number: 035290 (write"none"for two-party)
UNSPECIFIED
® 1 am the manager of this water system.The water system has been approved for A a rvices. There
are presently 1606 connection(s)in use.This will be the 1607 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 stale and local regulation.
Print Name of Water System Manager JESSE MATHEWS Phone 360-877-2728
Signature of Water System Manager�7� Date 1 211 6/2 0 2 4
This form may be scanned and available for public view at www.w.mason.wa.us.
JdEH Forms\Dainh'ng Water Revised 4/272021
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm gpd.
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.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA
Development within which WRIA http//ois co mason wa us/planning 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes_
Well Drilled ............................................................... 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 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)
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-Delemnination 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
mason(s).
Reviewer's Signatures:
Environ. Health: 'If1 Date
This form may be scanned and available for public view at www.co.mason,wa.us.
N,242