HomeMy WebLinkAboutWAT Application - 3/3/2025 WAT
MASON COUNTY Shelm n,41 Street W WAA 99584
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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 a roved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name of ApplicanCCindv Callaghan/grzLWerg Data: 2/4/2025
Mailing Address:23940 NE SA WA-3 Belfair Phone: 502-299-7180
Parcel Numbw:12329-41-90230
Type of Water System Reason for Application
IX PubliclCommunity Water System(2 or more 13 Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection). #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdnglsurfacewater ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
ff you have more than one residence connected of water system below g applicable—no
to this well, check the Public/Community Water Signature required)
System box.
Part 2: Water Connection Information APPROVED
Complete the section appropriate for the type of water connection being evaluated: MAR 0 3 2025
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
Name of water System: wake+ DKhrct It t
Water Facility Inventory(WFI)Number. 6535D (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.
❑,' 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.:reaeatlonal to full time). Please indicate on the following line the nature of
this change: _ � ^F ^ �^•J 61+iA� 9e aF (aa a.ne is
This water system is able and wiling 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 jak A"4 Phone blob 'a7S YX6
Signature of Water System Manager Date 13/1�
This form may be scanned and avaaable for public Mew at www.masoncountywa.gov
I\EH FO=\pno z water aevi 05Ngr1024 Page 1 of2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth R
❑ 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 draw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test within last year(attach to application).
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)
C Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in this future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Ttie 6,Chapter 6.68.040-Determination of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
t-•.. Unsatisfactory Determination:
Applicant a water supply does not appear adequate to meet the needs of as intended use for the following
reason(s6
Reviewer's Signatures:
Environ. Health: Date
This form may be sa nned and available for publk view at www.masoncountvwa.uov
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