HomeMy WebLinkAboutWAT2025-00036 - WAT Application - 2/25/2025 UJLft\� Coff) 2o25-r 01 1)?
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MASON COUNTY 415 N.6-Sonex
Shelton,WA 98584
Public Health & Human Services Shelton:360.4274610,Ext 400
Bel(sIc 360-275-4467,Exc 4W
Application for Determination of Water Adequacy
Instructions
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Complete Part 1. No tletermination con be made until Part 1 is fully completed.
Complete only the portion of Part 2 applying to the type of water connection utilized.
Submit completed application with any required attachments for review.
An approved building site plan must 2=WpanV this ap lication.
Part 1: Applicant/Parcel Identification- (�
Name on Applicant.L t' l 11 ��-IIM`,+j 1 1 tuatw
Mailing Address: �3�I 1a Ib, II
a xn njP Phone: �� ' ' "' ' !�o'
Parcel Number: A2DL)q-I- (U )())Ll. lJ' r5a�t-,TcnL.t ly.(.. —16� '4
Type of Water System Reason for Application
Public/Community Water System(2 or more Building permit CO Yt') Z�25 (wV
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 PubliWCommuni(y 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:JOA5µx"CroN G ![ITS 5 C: % ,,C
Water Facility Inventory(WFI)Number: '13063K (write-none'for two-party)
fQ I am the manager of this water system.The water system has been approved for/Oypservices,There
are presently �5D connection(s)In use.This will be the?_connection.
❑ 1 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 lime).Please indicate an the following line the nature of
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 MAvr Mu(LpµY- 014<so Phone 300.990.3 r99
Signature of Water System Manager Date �/Z 5/ZS
This form may be scanned and available for public view at www.masoncountvwa.aov
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Group B Water Systems -
❑ Satlafaclory bacteriological test within last year(aaach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft
❑ Well capacity Teat(attached to application) scam a
The well driller often performs well capacity tests at the time the well Is constructed. Re pd.
surs from
these tests are noted on the water well report. Results from these tests will be accepted. If the water
wall 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)
J Satisfactory Determination:
1 This detennimstlon does not address adequacy of the disbibution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with as applloabte MOE water resource regulations.
Recommanded approval indicates requirements of Sanitary Code.rive e.Chapter 6.68.040-Determination of
Adequacy for Building Nnnts are satisfied. Addidonal Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applkenrs water supply does not appear adequate to meet the needs of its intended use for the following
mason(s).
Environ.Health: _ _a s Sgnatures �
Date I (�
This form may be scanned and available for public view at www.masoncountrwa.aue
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