HomeMy WebLinkAboutWAT2025-00018 - WAT Application - 1/31/2025 WAT
MASON COUNTY
COMMUNITY SERVICES
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415 N 6th Street,Bldg 8,Shelton WA 98584 > 9eat r r'1
��' Shelton:(060)427-9670 exl 400 J Better:(360)275-4467 am 400 P bma:(3C}QM 9 I601J
`t 1„ FAX(360)427-7787 t"CG
C Application for Determination of Water AdequafN I I VS
t
Instructions
1. Complete Pan 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/ Parce It dentification
Name on Applicant: ,7 ,A, � p Date:
Mailing Address: tS�lt- 1�: one:
Parcel Number: - aLl
Type of Water System Reason for Application
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)31 Public/Community Water System(2 or more 15L Building permit t WW
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 then one residence connected of water system below if applicable-no
to this well, check the Publio(Community Water signature required)
nD^Uov I
System box. V // '� aaa... nnn
Part 2: Water Connection Information �rr7J '' 1
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI)Number:
(write'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 (i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and within pr ide water to this (these)connection(s)without exceeding
the limits of the water system or an li it et by s to d local regulation. I r, , '
Signature of Water System Manager Date�I 'L�
This form may be scanned and available for public view at www co mason wa us. 1
J:6 F. Drinldn6 wvm lk vi,eA 1,25,2019
Individual Water,Well
(�
pr Water well report(attached to application). Depth /1 .,vim ft. V
Well capacity Test(attached to application) //lJ gpm l0� apd.
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.
'qll Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA ham://gis.co.mason.wa.us/planning/cis.co.mason.wa.us/planning 14=15=16=220
Water use or limitation recorded................................... N/A i= Yeses
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 Daterminatlon:
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 W DOE 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 Growth Management requirements may apply. Chapter
36.70A RCW.
D 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. Heafth:�� Date �/l S LC
CSD Director: Date 2 oft
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