HomeMy WebLinkAboutWAT2005-00014 - WAT Application - 2/21/2025 ,� WAT�- DODI
MASON COUNTY
COMMUNITY SERVICES r:ECEIVED
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415 N 6-Street, Bldg 6,Shelton WA 98504, 'dx�4�2025
Shelton: (360)427-9670 ext 400 4 Beltair:(360)2754467 ext 400 a Elma:(360)482-52K9e
FAX(360)427-77e7 615 W. Alder Street
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is full le NTAL
2. Complete only the portion of Part 2 applying to the type of water connection utilized. f� �LT
3. Submit completed application, with any required attachments for review.
4. An approved building site Pisn must accompany this apellCatiOn.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Tint AaaA„ Date:a q
Mailing Address: 2-rt2 Al;i (sr -A I Phone: 2a(rtS 3� 0 Z -�
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Parcel Number: /2220—5�3_az:){2
Type of Water System Reason for Application !� �7
6Y Public/Community Water System (2 or more Building permit(J1 LvRo� -00 11 fly.
connections) ❑ Division of land:
❑ Individual water source(one connection), ti 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 PubliclCommun/ty 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: IAZZ t� V'/ 0/
Water Facility Inventory(WFI)Number. J
(write"none"for two-party)
. I am the manager oft this water system.The water system has been ap roved 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 (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 It its set by stat and Io I regulation.
Signature of Water System Manager ate /O
This form may be scanned and available for public view at www.c0.m nars at�nota
1:\EFI 17 m\Drfl d g Weer
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Individual Water Well
❑ Water well report(attached to application). Depth k.
❑ 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 drew-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//gis co mason.wa.us/planning 14[=15=16=22=]
Water use or limitation recorded................................... N/AII_Yeses
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I 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-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicanfa water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
rcQD Reviewer's Signatures: /
Environ. Health:l�� �L'-cal Date Zt
CSD Director: Date °'7