HomeMy WebLinkAboutBLD2025-00151 - WAT Application - 12/17/2024 FAT
MASON COUNTY uno
She4on,W 8594
lton,WA 9584
Shelton:360-427-9670,E.I.400
Public Health & Human Services eelfair.360-275-4467, Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Pert 1. No de term ce
ination can be made until Part 1 is tulle mpletetl.
12. 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 a Iication.
Part 1: Applicant/ Parcel Identification
Name of Applicant: James &Joyce Crosby Date: 121172024
Mailing Address:26125 Pillsbury Rd SW Vashon WA 98070 Phone: 206-854-5222
Parcel Number: 22127-2340030
Type of Water System Reason for Application n1c
0 Public/Community U�A Water System(2 or more ❑ Building permit -9 0a5 OU✓/
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 PublidCommumly Water 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:
Water Facility Inventory(WFI)Number: (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(Le.: recreational to full time). Please indicate on the following line the nature of
this change: Upgrading existina house within same footprint
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 Richard Dickinson Phone 360427-9670 x 652
Signature of Water System Manager Date 12/172024
This form may be scanned and available for public view at www.masonmuntvwa.gov
I\EH For Drinking Wmar R,ixd 05MM024 Page I or2
Group IS Water Systems
013Sa1�isfldory
bectsfiWogicel test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth h.
❑ Well capacity Test(attached to application) gpm dpd.
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)
'�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-Determination 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
reason($).
R vi er's Signatures:
Environ. Health: /\ Date
This form may be scanned and available for public view at www.masoncountvwa.aov
P.,2of2