HomeMy WebLinkAboutWAT Application - 6/14/2024 WAT
415 N.6*Street
SheMASON COUNTY -427-96 WA 400
lwa,WA 9 594
Shelton:360.42
COMMUNITY SERVICES nclfaic 360-2754467,EA 400
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Elma:360-482-5269,Ex1.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No detenninatic: 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.
q, An roved building site Ian must accom an this a licetion.
Part 1: Applicant/ Parcel Identification
Andrew Spear Date: 06/14/2024
Name on Applicant: P
Mailing Address 000 W Shelton Valley Rd,Shelton,WA 985one: 360-490-0324
Parcel Number: 420243490049
Type of Water System �/ Reason for Application
(� PubliUCommunity Water System(2 or more ltr Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels?_ SPL
❑ Well {y Boundary line adjustment
❑ Spnng/surtace 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 PubliclCommunhy 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
F
e of Water System: Huckleberry Ridge
r Facility Inventory(WFI)Number. AC464G (write'none°for two-party)am the manager of this water system.The water system has been approved for�.9 services.Therere presently�_connection(s)in use.This will be the 8 connection.am the manager of this system.This connection will be to upgrade or change the use of an existingonnection on this system(i.e.: recreational to full time). Please indicate on the following line the nature ofhis 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 state and local regulation.
Print Name of Water System Manager Melissa Cox on behalf of NWS Phone 360-876-0958
Signature of Water System Manager
` 6-('Von behalf of Date 06/14/2024
This form may be scanned and available for public view at••iNW co mamrt wa ui.
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P.\EH Foams\(kinking Wager
Individual Water Well
Fell report(attached to application). Depth ft
acity Test(attached to application) gpm gpd.
driller often performs well capacity tests at the time the well is constructed. Results from
ts are noted on the water well report. Results from these tests will be accepted. If the water
rt cannot be located by the applicant or if the water well report does not have a capacity test,
pacity test,which provides stabilization of draw-down antl recovery data, must be performedsed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hilg/1016-Comation.wa.us/plannina 14_15_16_22_
Water use or limitation recorded................................... WA_Yes_
WellDrilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ ] 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)
FAdequacy
isfactory Determination:
determination does not address adequacy of the distribution system,guarantee an adequate supply of
r indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
ommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determnadon of
for Building Permits are satisfied. Adddional Growth Management requirements may apply. Chapter
0A RCW.
atisfactory Determination:
cants water supply does not appear adequate to meet the needs of its intended use for the followingan(s).
�l r Reviewer's Signatures:
Environ. Health: Date
Thisfortry a nned and available for public view at www.m. als n wa m.
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