HomeMy WebLinkAboutWAT Application WAT
MASON COUNTY
COMMUNITY DEVELOPMENT
YnmxxrtituaeCmrn,iugtl�H.nenninr
415 N e"Street,Bldg 8,Shelton WA 98584,
360 427-9670 ext 4D0 4 Belfair: 360 275-4467 ex1400 4 Elma:(360)482-5269 ex1400
Shelton:( ) 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 ap2roved building site plan must accom an this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: DAN CHANDLER Date:
Mailing Address: 1092 E SOUTH ISLAND DRIVE Phone: 206-605-9246
Parcel Number: 22010-30-03051
Type of Water System Reason for Application
ElU
❑ Public/Community Water System(2 or more Building permit MCM'01510
connections) ❑ Division of land:
❑p Individual water source(one connection), #of Parcels? SPL
O Well (gnt,.nw&� ❑ 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 PubliclCommunify Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connectio ing evaluated:
Public Water yssem
Name of Water System:
Water Facility Inventory(WFI)Number:
(write"none'for two-party)
❑ 1 am the manager of this water system. T water system has been approved for_services.
There are presently connecti s)in use.This will be the connection.
❑ 1 am the manager of this system.Thi nnection will be to upgrade or change the use of an existing
connection on this system(i.e.:rec donal to full time). Please indicate on the following line the nature
of this change:
This water system is able and wi ng to provide water to this(these)connecdon(s)without exceeding
the limits of the water system or ny limits set by state and local regulation.
Signature of Water System Mane er Date
This form maybe scanned and available for public view at www.co.mason,wa.us.
J:,EH Fans p AL g W81 r Ra Is..I I "'_n lb
Individual Water Well
❑ Water well report(attached to application). Depth fl.
❑ Well capacity Test(attached to application) pm gpd.
The well driller often performs well capacity tee t the time the well is constructed. Results from
these tests are noted on the water well report. esults from these tests will be accepted. If the water
well report cannot be located by the applican or if the water well report does not have a capacity test,
a well capacity test, which provides stabiliz ion of draw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource 194antory Area (WRIA)
Development within which WRIA ht :l/ i . .m sonma.us/planning 14C= 1S=16=220
Water use or limitation recorded_...... .......................... N/A,[]_Vest_
WON Drilled ....................................................._.._.... Date
Individual Spring/ rface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this wa/minZte
provide at least 800 gallons per day;and/or
provides water at a rate of 2 gallonsed on the following observations.
Author of Statement_ Date
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use or; )
- Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guamntee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-Determination of
Adequacy for Building Permits are satisfied. Additional Gmwth 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).
A ' � Revviiewer's Signatures:
Environ. Health: e7�r�1'`w T Date
CSO Director: Date 2mr2