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HomeMy WebLinkAboutBLD2024-00817 MFG Home ADV2024-00112 Wat2024-00277 - BLD Application - 7/9/2024 CANCELLED -�R MASON COUNTY COMMUNITY SERVICES Permit No, PERMIT ASSISTANCE CENTER: BUILDING.PLANNING.PUBLIC HEALTH•FIRE MARSHAL 615 W.Alder StroeL Shelton,WA 98584 J U L 0 9 2024 Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone Bolrnlr.(360)275-4467•Phone Etna:(360)482-5269 615 W. Alder Street BUILDING PERMIT APPLICATION PROPERTY OWNER INFORMATION: —~ CONTRACTOR INFORMATION: l NAME:CMH Lacey NAME: ravt '��S�r.ye lsD✓` MAILING ADDRESS:6312 Martin Way E MATI G ADDRESS:�Q,:: 510 D CITY:La-y STATE:wa �p;sesls CIIY; STATE,1-'A ZIP:_15' PHONE#L(360)436-0246 PHONE: -7 7--j9310ELL: CIO PHONE#2: EMAIL: a� .,�y.�L LCC cywc,, •ev v" F_MAIL:HC742@darlionhornes.com L&I REG# Frar\/4_4L g EXP. 7 L(y C PRIMARY CONTACT: OWNER❑ CONTRACTOR OTHER❑ NAME _ 7Zt�� EMAIL�r�.�j C 1^trni(• ✓L. MAILINGADDRESS `a Z5(7 CITY�y�STATE ZIP—UZfV PHONE- --14L-qQ54 CELL v PARCEL INFORMATION: MEMO" PARCEL NUMBER(12 Digit Nwtdrer) Z Z C)(I '2 I q Lf DO Z ZONING LEGAL DESCRIPTION(Abby viated) FIRE DISTRICT STfE ADDRESS \D CITY W DIRECTIONS TO SITE ADD e O r dr 1S THE PROJECT KTTHIN 300 FT OF SLOPE(S)GREATER THAN 14%' YES[] NO SNOW LOAD:a psf IS PROPERTY Wf CHIN 200 FT OF THE FOLLOWIING: (Check oAdmt egply): SALTWATER❑ LAKE❑ RIVEWCREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF-[] STREAM❑ - TYPE OF WORK: NEW 6r'ADDITION❑ ALTERATION❑ REPAIR❑ OTHER ❑_ USE OF STRU RP Gervgr.,,,emra,ew Bldg,EYe} IS USE: PRIMARY SEASONAL❑ NUMBER OF BEDROOMS_NUMBER OF BATHROOMS Z. HEATED STRUCTURE? YES mote Bide,) YES fA-(V q RkW❑ NO❑ DESCRIBE WORK Nt w IM q SOUARE FOOTAGE:tP^'pareQl I ST FLOOR _sq, L 2ND FLOOR---sq.fL 3RD FLOOR sq.ft. BASEMENT sq.& DECK_ sq.IL COVERED DECK sq,& STORAGE sq.ft. OTHER sq.fL GARAGE eq.ft.Atraehed❑ Detached{] CARPORT ^,sq.k Attached❑ Detached❑ MANUFACT URED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED* MAKE_ <�l �d MOAEL'� nD %�t5 YEAR�Z- LENGTH 7 Z-- WIDTH Z7, Bffi3ROOM3 � BATIiS __SERIAL NUMBER j g D NVIKONMENTAL HEALTH, SEWAGE)SEWER SOURCE: SEPTIC SEWER❑ / NEW tr' MSMG❑ PLUMBING IN STRUCTURE? YES NO❑ Ijyes,attach cowTIeted Wour Adequacy Foray PERIMETEWOUNDATION DRAINS PROPOSED? YES 0 NOV EXISTING SQ.FT. EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS OWNER acknowledges that sulnrilselon of Inaccurate Information may result In a stop work order or permp revocation,Acknowledgement of such Is by signature below.I declare that I am the owner and I farther declare that I am entitled to receive this permit and to do the work as proposed.I have obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this project. The owner or legal representative,represents that the information provided is accurate and grants employees of Masan County access to the above described property and structure(s)for review and Inspection,This permittapplica0on becomes null 6 void If work or authorized construclion is not commenced wkhln 180 days or I construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTMTY OF THIS PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON COUNTY CODE 14.08.42) //y J X (0— 1V `Zp2"i Sig tur©of O (Must be signed by the OWNER) Date DEPART. ENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT FIRE MARSHAL PUBLIC HEALTH ! 7 '' r =: ; .: - CANCE Vid oq,. 4 1 ¢* Y..4 S 4 E.PAULA JOHNSON 141 Ck s 57-s L- V LZ 7= SLO I lNTo rev' S,,ej N �0LXS WELL 2eann0-, . C- t%k 200 ;a Se-D-C 7a.7,� 2-7 X-7 z 2-Co=-pa--tmer.t w-th Effiuent FLIter k-L . -ZOO C-aLOrl P-a=-z Cha=- Lp vt 05. Valve Con=o--, Box f , } J _ - L s 15D A7 A XX ?S, tA CANCELLED Mason County Building Division MANUFACTURED HOME PLAN REVIEW SPECIFICATIONS UNIT INFORMATION: *****Snow Load ':Sri Make liee j Model 'Tv-ncx� �&'t Year�_t,L`P Square feet Width 2-7 Length Z Singl Doubl /triple-wide(indicate) C7NE1W6r Replacement indicate) All footings must be min. 12" below natural grade within 24" of the skirting when perimeter blocking is required. When a relocated unit AND the manufactures specification are not available the HUD 24 CFR 3285 must be used for required pier plan,standards and set-up. Allowable Pressure(Pound Per Square Foot)No Allowances made for overburden pressure,embedment depth,water table height,or settlement problems Soil bearing is assumed at 1500 psi If set-up is using a greater soil bearing capacity a soil report from a design professional is required Fill(compact or uncompacted) Compaction Report required through Special analysis Peat or organic clays Compaction Report required through Special analysis SET UP SPECIFICATIONS: I Manufacturer's Pier Plan 71 HUD24 CFR part 3285 FOUNDATION: Check the type of foundation and attach detail plans from manufacturer's or the ANSI A225.1/ HUD24 CFR part 3285 —1 Pads O Concrete(pre-cast) O ABS Pads(Poly)provide manufactures specification with capacities. (71 CPntinuous concrete footing(runners) Slab ANCHORING: C) Moagnum und 7 Concrete-2500 PSI 71 J-bolt f'Expansion bolt For new units,this information can be obtained from the home retailer or contractor. Previously owned units,which manufacture's instruction are not available must utilize the HUD24 CFR part 3285 code for installation. Washington State law requires that a certified installer install manufactured homes. The undersigned I hereby acknowledge he/she does understand that the Mason County submittal and review processes will be based on the information provided herein and will be verified at time of inspection. Applicant/Dealer/Installer(indicate) Date L12--Zy 1 NameQM-es ycgZze�1 Parcel# ZZ-O\'A- BLD# --- Mason County Department of Community Development Small Parcel Stormwater Management Application/Worksheet (page 2 of 2) Based Upon the information you have provided a Stormwater Site Plan IS Required for this development activity. Title 14,Chapter 14.48 of the Mason County Code(MCC)regulates compliance requirements for Stormwater Management in this jurisdiction.A complete copy of the ordinance can be found on the Mason County website: http//www.co.mason.wa—us/code/commissioners/index.htm Please follow the links to"Title 14,Chapter 14.48 Stormwater Management". Regulated activities shall be conducted only after Mason County Public Works approves a stormwater site plan (Mason County Code Title 14 Chapter 14.48 section 14.48.70).You will receive a copy of the Public Works document entitled"Managing Storm Drainage on Small Lots,The Small Parcel Stormwater Site Plan".This document will assist you in preparing the necessary information and plans for Public Works to review and approve. Per Department of Public Works this document will constitute an approved plan if all of the relevant details* are to be installed in their entirety AND no part of the stormwater system adversely affects any septic system(see Environmental Health information below). If an alternative system is to be used a plan will need to be submitted to Public Works for approval. A design by a registered professional may be required for more complex sites. *'These details are found in the document Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan on the pages that begin with"Handout" PLEASE INITIAL BELOW TO INDICATE THE STORMWATER MANAGEMENT PLAN FOR THIS SITE A)�!—C—The relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed in their entirety AND the system will be located as not to adversely affect any septic systems on this,or any other,parcel. B) An alternative plan and/or professional design will be submitted to the Department of Public Works for approval AND the system will be located as not to adversely affect any septic systems on this,or any other,parcel. If you have further questions pertaining to parcel drainage and stormwater management Mason County's Public Works Department can provide additional instructions,guidance and examples.(Section 14.48.130)contact Public works at: Phone: (360)-427-9670 EXT.450 Mail: P 0 Box 1850, Shelton WA 98584 Physical:415 N 6th St,Shelton WA 98584 If this development has,or will have,a septic/drainfield system you may need to contact Mason County Division of Environmental Health to ensure that the stormwater system will not adversely affect the septic system of this,or any other,parcel.You may also wish to consult with the septic design professional involved with the project.Mason County Division of Environmental Health can be reached at: Phone: (360)-427-9670 EXT.352 Mail:P 0 Box 1666, Shelton WA 98584 Physical:426 W Cedar St,Shelton WA 98584 A condition will be added to the building permit that states,in part,that all conditions the stormwater site plan will be met prior to a request for final inspection of the building permit. Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation. Acknowledgement of such is by signature below.I declare that I am the owner,owner's legal representative,or the contractor.I further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above- described property for review and inspection as may be required. Owner/Agent/ o tractor ircle one)Date: Page 2 of 2 CV�tl� b L L LED Name-\anke5 grca?et I Parcel# 2 ZO Z\- e-A4 00-L BLD#___ Mason County Department of Community Development Small Parcel Stormwater Management Application/Worksheet (page 1 of 2) Per Mason County Code,Title 14,Chapter 14.48 a stormwater site plan is required whenever a building application is made for residential development,or redevelopment',with more than 2,000 square feet of impervious surface 2. 'Redevelopment means,on an already developed site,the creation or addition of impervious surfaces,structural development including construction,installation or expansion of a building or other structure,and/or replacement of impervious surface that is not part of a routine maintenance activity,and land disturbing activities associated with structural or impervious redevelopment. 2Common impervious surfaces include,but are not limited to,rooftops,walkways,patios,driveways,parking lots or storage areas, concrete or asphalt paving,gravel roads,packed earthen materials,and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater.Open,uncovered retention/detention facilities shall not be considered as impervious surfaces. m,. _ ,T . .w Calculate Impervious Surfacalplewe Co Surface Type Length X Width = Area *All dimensions in feet Buildings -Z X 2- X = Measurements for buildings are taken at the X _ perimeter of the farthest projections(example: eaves/gutters) X = Driveways — X 2kp = t SO X = Length of drive begins at the right of way X = Parking Areas X = X = Any paved. gravel or packed area per definition above table X = Patios/Walks X = X = Any paved, gravel or packed area per definition above table X = Others X = — X = if the total impervious area of the proposed site —- X = development is greater than 2000 square feet a Small Parcel Stormwater Site Plan is Required Total Impervious Surface Area(sum of all areas) If the Total Impervious Surface Area is LESS THAN 2000 Square Feet,please read,acknowledge and sign below. Based Upon the information you have provided a Stormwater Site Plan IS NOT required for this development activity. Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation. Acknowledgement of such is by signature below.I declare that I am the owner,owner's legal representative,or the contractor.I further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above- described property for review and inspection as may be required. X Owner/Agent/Contractor(circle one)Date: If the Total Impervious Surface Area is GREATER THAN 2000 Square Feet,please read,acknowledge and sign the information provided on page 2 of 2. Page 1 of 2 CANCELLED 4/0/25 MASON COUNTY BUILDING DEPARTMENT MANUFACTURED HOMES Mason County Permit Document 0 1 APPROVED MASON COUNTY BUILDING INSPECTOR CHANGES SUBJECT TO APPROVAL DATE DOCUMENTS ATTACHED TO APPROVED MUST COMPLY WITH PERMIT LANS CONDITIONS ITE PLAN YES PLAN REVIEW CHECKLIST YES UMBER OF PAGES -3 Plans to be kept on site IF ABS PADS ARE USED,A SITE INSPECTION BY These plans must be on the job site THE BUILDING DEPARTMENT TO CHECK SOIL for inspection COMPACTION IS REQUIRED PRIOR TO HOME DELIVERY. Changes Submit changes for approval prior to performing work FOOTING PLAN,SITE PLAN, AND INSTALLATION INSTRUCTIONS MUST BE ONSITE FOR ALL INSPECTIONS. ALL FOOTINGS MUST BE A MINIMUM OF 12" BELOW GRADE FOR FROST DEPTH S SITE COPY Reviewed for Code Compliance Mason County Building Department TEMP© SERIES 27x72 Hey Jude �� WID% 5 BEDROOM,2 BATH-U20 SQ FT. 3" , E Agate Rd - Lot B W63 W a REVIEWED FOR CODE COMPLIANCE MASON COUNTY BUILDING DEPARTMENT FLEX2 ......................... _ ........ ........ .._._........--. �...................... .._..—. B,S•, W-18 W—W 1M-18 W63 W63 ❑ _ _.-- BEDROO w ' r - KITCHEN `- -- FLEX4�1 9'-0-_x a'-9__.. FLEX 2. ..�� _ a'-9-x 12'-8- .{ r El' a -- a FLEX a'-a-x r-z- Ell r- t r _ tvuCuacs i Lm"ROOM x----- `1 PRIMARY � 4~X OM BEDROOM 4 BEDRO 3 BEDROOM 2 3 �� BEDROOM 4'-V x 12'-5' vw x Ira- '------ 9•-G'x 12•-G' -..a 'Xzrar,e� WmAraGe �� J) W-0 W"63 W41 W-63 7 L wan Hama-omm.>r amiew:: mar:w.mmeaer mo:wm a.�n:m M.,'�s,�,ar�.n.v..o:amv»wcew nvc.mxa /ffV.VM2023 419 W Oww*W by Lww=AmOm cam:Foundatw Ptw S+ts mory 01010 600orE WA /lN}MI�W#b 27 FT 4 INgmf� i X MF 01`aa Iaa Ca Te�now" .A , - 'A"", _ vow 1lMREMr P2-T*,=-n Ny aYIM✓✓✓ looms lr� 72 FF D N s��v y{� IN9 Pv aa; s pw m pzs& o-. wa cw Oad0 w s "coma FAGW 172 {aro(OA), 21 25 es Ons 7;Sun $04 far Ammo me orw dom a OR coft tldl m ImYAM"C FRAW pOESIS rAAtfs 2€II nwot pw" T,18iP S.NAMMAA€VLU k pw" prr ep"" Fsr ca� RMMa Mw " R n � Mier pYr w F.W.s. PM to Tkp,sFraN &-400mom � Ll.:2 r: .c ssseaM■vssN lw�,w -.^- NAX 6 FT s W 15 g"dw" Rl,R2 $row wooed is IN.xs N.a N poetic a�apYb6 - - (TaAMr7A) ASA j�A�R__.e._.,._,m.,.�.,._ wtw aa� seer set ar 3' 1, xe sam • i xx loll i i Sj 3 } I t I _ s. CW6ny�. 1 rTl REVIEWED FOR CODE COMPLIANCE MASON COUNTY BUILDING DEPARTMENT .-� 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. 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(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14_15_16_22_ Water use or limitation recorded................................... N/A Yes Well Drilled ............................................................... Date 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 W DOE 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(s). Reviewer's Signatures: Environ. Health: Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 k, CANCELLED t MASON COUNTY Mason County Permit Center Use: COMMUNITY SERVICES ADv 2c)24 - w 112 Building,Planning,Environmental Health,Community Health 615 W.Alder St.—Bldg.8,Shelton,Wa 98584 Date Rcvd Phone:(360)427-9670 ext.352♦Fax:(360)427-7798 Fee: $130.00 Request for Administrative Variance for Reduction in the Required Setbacks For administrative review, the minimum variance on a setback request is 5 feet from the side yard lot lines and 10 feet for front and rear lot lines or any access easement.Request for further reduction requires a standard variance. Setbacks are measured from the furthest projection of the structure, including roof eaves and gutters. W Applicant/Owners: �,11�1 TI -1 I b Ylr1L��Y1 C, Mailing Address: D M&A Y-) W-64d E City: L r' i ,1 State:VJ A Zip: q851LP Telephone: o (Do - 4,39). oo-�44 tp Email: n h 0 rY,,&' U YYl If this reduction is tied to a building permit,please give permit case number. BLD Parcel Number(s): aiO I -o� I - �y�n Zoning ) 1 -5 Site Address: � � W Requested setback variance: ft. ❑ Front ❑ Rear Side w6 " ft ❑ Front ❑ Rear ❑ Side ft. ❑ Front ❑ Rear ❑ Side ft ❑ Front ❑ Rear ❑ Side Front Setbacks-From access easements and road right of ways. Minimum 10 feet. Rear Setbacks-From the rear property line. Minimum 10 feet. Side Setbacks-From the side property line. Minimum 5 feet except for certain shoreline designations. An illustrated site plan is required. Your site plan must show the following: north arrow, abutting street or easements, and set backs to all property lines and existing buildings, slopes, surface water, wetlands, critical areas, septic,well and driveway. Show all proposed new development. abb f: FRONT AND OR REAR YARD REDUCTION REQUESTS: For existing lots of record as of March 5, 2002; You must meet one of the following: 1) One of the following exists on the lot(check all that apply): ❑ a) steep slopes, wetlands, or streams present; ❑ b) soils that restrict building or septic development; ❑ c) lot width at the front yard line of no more than 50 feet; ❑ d) lot size of no more than one-fourth acre; xisting improvements of buildings, septic systems, and well areas. S E YA6 REDUCTION REQUESTS: r exi ng lots of record as of March 5, 2002; You must meet one of the following: 2) One of the following exists on the lot(check all that apply): ❑ a) steep slopes,wetlands, or streams present; ❑ b) soils that restrict building or septic development; ❑ c) lot width at the front yard line of no more than 50 feet; ❑ d) lot size of no more than one-half acre; L e) existing improvements of buildings, septic systems, and well areas. Explain how these circumstances preclude a reasonable development proposal from meeting the setback standard for Rural Residential 2.5, 5, 10, or 20 zones. + prlv-� ILA�MLA-)_ 2)0&1!�L Owner/Agent(please indicate) Signature Date Official Use Only Approved by: Date Denied by: Date Reason for denial: CANCELLED WAT ,2. _ ��gI 415 N.61h Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 Building,Planning,Environmental Health,Community Health Elma:360-482-5269,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 1: Applicant/ Parcel Identification Name on Applicant: fgQV%\ _40V Date: -Z -I q Mailing Address: 1�0 ?>0 1( SS?D6) L4( qv A- Phone: _L 1eQ-74 Z-a y3y Parcel Number: �2 b�� —ZI• �tiC�OZ �ype of Water System Reason for Application Public/Community Water System (2 or more Building permitlbWC( 624 -DVb i - 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 Public/Community 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: (�[�i1 Water Facility Inventory(WFI)N m er: nO vi e (write"none"for two-party) ❑ 1 am the manager of this water system. The water system has been approved for C;�, services. There are presently k 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 (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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. .1:\E1I Forms\Drinking Water Revised 4/4/2018 1 k 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. 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(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14_ 15_16_22_ Water use or limitation recorded................................... N/A Yes Well Drilled ............................................................... Date 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) L. 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 W DOE 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. l Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Reviewer's Signatures: Environ. Health: Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2