HomeMy WebLinkAboutWAT2025-00045 - WAT Application - 2/19/2025 WAT Zo�'�
MASON COUNTY 415N.6°56&4
Sbalran,WA 985R4
Shelrua:360- -96?0,Ex 400
Public Health & Human Services eelfair:360 275z?saw?,Ext 400
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 approved building site plan must accompany this application.
Part f: Applicant/ Parcel Identification
Nameof Applicant RrrE dpslul+ye, Date: ,2-l4-x5
Mailing Address: t 5 e JA2A)L__Phone:
Parcel Number. DOD
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more ❑ Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdng/sudaos water ❑ Other(explain)
X Other(explain - 1 too hpbot &m,p A /J)"Ne
-7"� ❑ 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 PubliclCommunity Water signature required)
System box.
Part 2: Water Connection Information
I
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: f�-� CSl+r.lieµ Snweltrs+,r F:eid
Water Facility Inventory(WFI)Number: 6 Mir 35'3 (write'none"for two-party)
r I am the manager of this water system.The water system has been approved for 74B services.There
y are presently 1A connection(s)in use.This will be the 18 onnaction.
lx I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(Le.: recreational to full time).Please indicate on the following line the nature of
i 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 limits set by state and local regulation.
Print Name of Water System Manager--i cep t 601 Phone 3!O-N16•NJ 1
' 14-15, Signature of Water System Manager�iA ��-= - Date 2-
i
This form may be scanned and avallable for public view at www.masoncountvwa.twv
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Group B Water Systems
x Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
yJ<4 1 Wet irz
X, Water well report(attached to application). Depth a ft.
Inkl14, 4W 1
x Well capacity Test(attached to application) [Cr?--gPm / gpd.
The well duller 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. 1f 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.
x Satisfactory bacteriological test within last year(attach to application).
Individual Spring/Surface Water
Cl 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 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,Tltia 6,Chapter 6.68.040-Deteminabon 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
reasons).
Reviewer's Signatures:
Environ. Health: Date
This form may be swnrted and available for public view at www.mewnoountywa.00v
Page 2 of 2
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