HomeMy WebLinkAboutWAT2025-00040 - WAT Application - 2/10/2025 WAT oa5 o
MASON COUNTY l415 N.tor,W*Street
Shelton,0, t.400
SMlton:360a27-9670,Ezt.400
Public Health & Human Services Belfair:360-275-4467,Ent.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 1: Applicant/Pa?r el Ident�ation ^ '
Name on Applicant: �IlfeSA / ✓�Viell Date: 241 V 24
pZ5-
Mailing Address: 7 Phone: $25- — Jo S 3 s�V
Parcel Number: 32DZ1- I o 8/ewe/taut 1 7--
Type of Water System Reason for Application
Public/Community Water System (2 or more ,� Building permit�ICI2o25-m 141
3 .
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 than one residence connected of water system below if applicable-no
to this well, check the Pubfic/Community Wafer signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: S�'IOfIL.rGF'� E�� '>7�5
-rp1 WQ fY �.O
Water Facility Inventory (WFI) Number:�,20 - I (write"none"for two-party)
❑ 1 am the manager of this water system.The water system has been approved for_serviceIThereare presently connection(s) in use.This will be the connection.
`oLtam the manager of this system.This connection will be to upgrade or change the use of an exiconnection on this system(i.e.:recreational to full time).Please indicate on the following line thethis change: ExnAinq n c1 n- lovileting 'rzmnit-
This water system is able andwilling to provide water to this(these)connection(s)without exceeding e
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager. �1 1 Phone L314 -027
Signature of Water System Manage -2 Ic 2o2
- This form may be scanned and available for public view at vim.masoncountywa.gov
1NiH Foetus\finnkiag Water Rev 05X8n024 Page 1 of2
a 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) gprn 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 lest,which provides stabilization of drew-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)
Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate suI
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource reg
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-DetermiAdequacy for Building Permits are sabered. Additional Growth Management requirements may appl36.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the follo
reason(s).
�{n( 1 Revie es Signatures:
Environ. Health: 1`�` IM4 Cd V)' I Date S
This form may be scanned and available for public view at vmw masoncountywa.gov
N,2of2