HomeMy WebLinkAboutWAT2025-00034 - WAT Application - 3/12/2025 WAT_a - 0;00
MASON COUNTY 41 W Street
Sfielton,WA 98584
Shelton:360427-9670,Ext.400
Public Health & Human Services B.Hir..3W2754467,ExL 400
Application for Determination of Water Adequacy
Instructions
11. 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. Ana roved buildingsite Ian must accom an this application.
Part 1: Applicant/ Parcel Identification
Name of Applicant:
Donald Miniken Date: 2-1-25
Mailing Address: 7110 PACIFIC HWY E, Millon,WA Phone:
Parcel Number: 22104-4150030
Type of Water System Reason for Application
.� Public/Community Water System (2 or more Building permit 7B W j2OA5—&JL
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 PubficlCommunify Wafer signature required) nn
System box. vv'�LZO1
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Benson Ridge
Water Facility Inventory(WFI)Number: AD830N (write"none"for two-party)
.�' I am the manager of this water system.The water system has been approved for 6 services.There
are presently 4 connection(s)in use.This will be the 5 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.:recreational to full time). Please indicate on 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 PAN Davis Phone 360-6014375
Signature of Water System Manager Oit
P44,d4, Date 2-1-25
This form may be scanned and available for public view at www masoncountvwa"Gov
]:\EH Fame\DriNdag Water Revised OWM024 Page I of 2
Group B Water Systems
Satisfactory bacteriological test within last year(attach to application). (O(Z*ZICA bo
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm gpd.
The well driller often performs well capacity tests at the time the well is constructed. Resullpemeed'
these tests are noted on the water well report. Results from these tests will be accepted. I
well report cannot be located by the applicant or if the water well report does not have a ca
a well capacity test,which provides stabilization of draw-down and recovery data, must be
by a licensed contractor.
❑ Satisfactory bacteriological test within last year(attach to application).
1
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 Boo gallons per day;and/or
�]]]3 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,Title 6,Chapter 6.68.040-Detecnination of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meal the needs of its intended use for the following
reason(s).
Re Signatures;
Signatures:
Environ. Health: `d y V I Date
This form may be scanned and available for public view at www masoncoun�aovv
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