HomeMy WebLinkAboutWAT Application - 1/30/2025 _
' MASON COUNTY W H1
COMMUNITY DEVELOPMENT L
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415 N 6-Street,Bldg 6,Shelton WA 98584, 11rArr/LGf l
Shelton:(360)427-9670 ext 400 4 Belfair: (360)2754467 ext 400 d Elma:(360) 25269�d d00
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No demmunavon can be made until Part 1 is fulty 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. Ana roved buildingsite Ian must accompany this a2plication.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Co IhT Date: //3o /W ZS
Mailing Address: 27r/,�' S��i�6n>,Ot, Phone: 490— 17 V03
Parcel Number: 3P'22-1 y — /B-fI/ 2—
Type of Water System Reason for Application
XPublic/Community water System (2 or more �, Building permit'Vj A 70-601,
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(pleaseindicate+ame
If you have more than one residence connected of water system below if applicable—no
to this well, check the PublidCommunity Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
f� l Public Water System
Name of Water System: r a, +n r jefl� rQ SSr i� J71 P
Water Facility Inventory(WFI) Number: r bnf
(write"none"for two-party)
P, I am the manager of this water system.The water system has been approved for 2- services.
There are presently / connection(s)in use.This will be the connection.
❑ 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:
This water system is able and wilting to provide water to this (these)connection(s)without exceeding
the limits of the water system or any
'limits
/set by state and local regulation.
Signature of Water System Manager ` ✓' // Date j 3�
This form may be scanned and available for public view at wwylr.co.mason.wa.us.
r:1EH Forme\Drinking Water Revised 1IM018
Individual Water /Well
p Water well report(attached to application). Depth
Well capacity Test(attached to application) 2 D gpm gpd.
The well driller often performs well rapacity 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,flqis.m.mason.wa.us/planning 14= 150 160 220
Water use or limitation recorded................................... N AE2L Yeses q
Well Drilled ............................................................... Date II Z O / /
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source can provide at lead 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:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
/11 Reviewer's Signatures:
Environ. Health: EE�'�li/ h Date
CSD Director: Date 2 ufx