HomeMy WebLinkAboutWAT2025-00145 - WAT Application - 7/14/2025 WAT DR6- ccV A I
415 N.6th Street
�� ��:,,. Shelton.WA 98584.,' MASON COUNTY RECEIVED She
Shelto
Pr 1 r . n:360.427-9670,Ext.400
COMMUNITY SERVICES Watt:360-275-4467,Ext.400
r,' Suiting.Pie+uw,a t nvu°mental Health Corm urnty Health
J U L 1 2025 Elm 360-482-5269,Ext.400
Application for Determinati6Waikbacy
Instructions
1. Complete Part 1. No determination can be made e tilPaar 1 is ter fullyconnectioncompleted.
letei.ized.
2. Complete only the portion of Part 2 applying type
3. Submit completed application, with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification1- � .7 / i I r pp�
Name on Applicant: ,i�RCi rk-vh v� Date: / 4
81 C ri r ' uh;�,Phone: /Y.-0(0 -- (c i I — 5 f)?g
Mailing Address: YAP
Parcel Number: 32104-54-00063
Type of Water System Reason for Application Building permit{3LQR6 00831 1
Public/Community Water System (2 or more ❑ Division of land:
connections)
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ Other(explain) ❑ Replacement or Remodel (please indicate name
11 of water system below if applicable—no
If you have more than one residence connected signature required)
to this well, check the Public/Community Water 9
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: Alderbrook
Water Facility Inventory (WFI)Number: 01050 B (write`none"for two-party)
VI am the manager of this water system. The water system has been approved for 636 services. There
are presently 535 connection(s) in use. This will be the 536 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
Brandy Milroy Phone 360-877-5249
Date 06/21/2024
Signature of Water System Manager ___
This form may be scanned and available for public view at www,co.mason.wa.us.
Revised 4n7n021
JAMForms\Drinking Water
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.
❑ 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 Evaluatio_n {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(s).
' ls� Reviewer's Signatures: -_..;_..
Date 8/7/25
Environ. Health:
This form may be scanned and available for public view at www.masoncountywa.dov
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