HomeMy WebLinkAboutWAT2025-00519 - WAT Application - 5/6/2025 WA'!' 2026 - 00�� l
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MASON COUNTY Shelton,WA 985B!
COMMUNITY SERVICES Shelton:3110 4279670,EXI_400
Belfair.360 275 44167,Exl_400
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Application for Determination of Water Adequacy
Instructions
i. Complete Part 1. No determination can be made until Part 1 is (oily coo feted.
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 Applicarn: Chad Burgess Date: 05/0612025
Mailing Address: Plwine: 360-7021-2794
Parcel Number: 42024-34-90051
Type of Water System Reason for Application
V Public/Community Water System (2 or more Building perrnit 3Vt2 i2 -vOOP.)`0
connections) ❑ Division of land:
❑ Individual water source (one connection), # of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Sprinyisurface water ❑ Other (explain)
❑ Other (explain)
❑ Replacement or Remodel(please indicate name
it you have me e than one residence coNlrtected of water system below if applicable—rt0
to this weal check the PublcJCornrnurntty Water signature required)
System box. /'r--��P p�
Part 2: Water Connection Information MAY 2
Complete the section appropriate for the type of water connection being evaluat�eAdSQNCOUNr pk.,, 2°25
Public Water System R ,T r,S ,4L Hz
Name of Water System: Huck1ebe.�f Rid
.p_ ge, ...
Water Facility Inventory (WFI) Murnber: AC464G (write"none"for two-party)
I am the manager of this water system_The water system has been approved for 9 services. There
are presently 7 connection(s) in use. This will be the 8 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 (those) connection(s) without exceeding the
hinds of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Melissa Cox on behalf of NWS Phone _ 360-887670958
Signature of Water System Manager /.. 1 behalf o€NWS Date 2Q25
This form may be scanned and available for public view at www.co.mason.wa.us.
l:.iHH PURLS'.DrInkimg N'aw Retitled 4m,TOZ1
Individual Water Well
❑ Water well report (attached to application). Depth It.
O Well capacity Test(attached to applications) ._____gpm........ gpd.
The well driller often performs well capacity tests at the lime 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
❑ I have reason to believe that this water source can provide at least B0O gallons per day; and/or
provides crater 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 distrihuhon system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with al applicable WUOE water resource regulations.
Recommended approval indicates requirements of Sanitary Cade,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied_ Additional Growth Management requirements may apply_ Chapter
36.70A RCN_
Unsatisfactory Determinations
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:O
Environ_ Health: CiMV/y _ Date S 7l zJ
This form may be scanned and available for public view at www.co.mason.wa.us.
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