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Home My WebLink AboutWAT2025-00067 - WAT Application - 3/28/2025 -� Baskt-5-#01 c. OV Q,4,‘ WAT 2025 - 00001 MASON COUNTY Rkc JSVeED J L Shelton,WA 98584 >tr Shelton:360-.1!J.76, ^�1 Public Health & Human Services Belfair:360-25- 4r Ex ti 0 615 W.Alder Street 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: Due-, L4 /A 5 Date: 3 7- Z Mailing Address: 7 01 C". "D7, Phone: 2 S3 2 31)- y '2lo Parcel Number: -22 02-r77 (G O 0 O Zp Type of Water System Reason for Application lid Public/Community Water System (2 or more 01 Building permit connections) ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well El Boundary line adjustment 0 Spring/surface water ❑ Other(explain) 0 Other(explain) 0 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 4UCL20 Z S _0 0011 Name of Water System: Water Facility Inventory (WFI) Number: /I /4 (write"none"for two-party) I am the manager of this water system. The water system has been approved for vZ services. There are presently oZ connection(s) in use. This will be the a connection. 0 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 Z / "// S Phone 2S5 2 30-2/T$0 Signature of Water System Manager <ZG=W Date 3 -Z 2- 2 S This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Page I of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). 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. O Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection ❑ I 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: /4 Applicant's water supply does not appear adequate to meet the needs of its intended use for the f9Aowing reason(s). 90+0 . Reviewer's Signatures: l ��'ti 9rp, Environ. Health: Date ;( W70 l f/ <<G�, cb This form may be scanned and available for public view at www.masoncountywa.gov 4 l y Page 2 of 2 F? e, MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 OD . BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELNIA:360-482-5269,EXT 400 FAX:360-427-7787 DOUG WILLIS 701 E DANA DR SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00027 3070 E Harstine Island Rd S 220257600020 The 2-party water system, Sweetwater(220257600020/220257600020), has been reviewed and is hereby APPROVED for 2 connections. Please continue to follow best management practices with maintaining your water system including regular water analysis, landscaping, keeping wellhead area free of contaminants, and stormwater management around the water source. If you have any questions, please contact me at 360-427-9670 Ext.353 or email at danderson@masoncountywa.gov Sincerely, David Anderson Environmental Health Specialist Mason County Environmental Health APPROVED MAY 0 7 2025 MASON COUNTY ENVIRONMENTAL HEALTH DJA