HomeMy WebLinkAboutWAT2025-00173 - WAT Application - 8/21/2025 1WAT 22 - OI73
415 N.6th Street
Shelton,WA 98584
u- t•'.{fib.
/ MASON COUNTY Shelton:360 427-9670.Ext.400
1= ,l� ,:. ' COMMUNITY SERVICES Belfair:360-275-4467,Ext.400
� 1 Elma:360-482-5269,Ext.400
�1s'/ BuPiing,Planning,[nvitonmentalHealthCommunityHealth
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination cant be maying adee type a Part
f waterconnection full
. iltutilized.
2. Submit only the portion
with anyart 2 n required attachments for review.
3. Submit completed application,
4. An a••roved buildin• site 'Ian must accom•an this a••lication.
Part 1: Applicant! Parcel Identification 08/21/2025
Applicant: Keith Groom Date:
Name on App 2538614075 •
t c lint WA 9$042 Phone:
Mailing Address: 14526 SF ?44tt� �t 5-47
Parcel Number:
42204-50-00047 Division-block-lot: i
Type of Water System
Reason for Application
Building permit
i�! Public/Community Water System (2 or more ❑ Division of land:
connections)
#of Parcels? SPL
❑ Individual water source(one connection), ElBoundary line adjustment
❑ Well
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel (please
indicate name
of water system below if app
If you have more than one residence connected signature required)
to this well, check the Public/Community Water
System box. Signature KET77tOkOOM
Part 2: Water Connection Information Email Address kcgroom77@gmail.com
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: LAKE CUSHMAN SYSTEM 5
Water Facility Inventory (WFI) Number: 035290
(write"none"for two-party)
❑ I 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.
EllI 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: Keith Groom
This water system is able
willing
limitst setprovide
b watere to
local regulation.
e) Phonewithout exceeding the
a
limits of the watersystemany
JESSE MAl HEWS Phone 360 877 9668
Print Name of Water System Manager 08j22/2025
Signature of Water System Manager
9 . ;,..i::...r„.,,::, Date
This form may be scanned and available for public view at www.co.mason.wa.us.
1\EH Forms\Drinking Water
Individual Water Well
Depth
ft.
❑ Water well report(attached to application). De p
❑ Well capacity Test(attached to application)
9Pm 9Pd
l is
The well driller often performs well wellreport.city ts at the time the Resu is from thesetlests will be constructed.
Results
the water
wellthese tests are noted located the waterapplicant or if the water well report does not have a capacity test,
report cannot be by the data, must be performed
a well capacity test,which provides stabilization of draw-down and recovery
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto I/ is co_.____nwsonwa us/pt__ a--nrnna 14_15_16_22__.
N/A Yes
Water use or limitation recorded
Well Drilled .......................................... . .. . ..
Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
O 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.
Date
Author of Statement
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
Satisfactory Determination: guarantee an
This determination does not address adequacy of the distribution system, WDOE watnradequate supply
regulations.
water indefinitely in the future,or guarantee compliance with all applicable Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
I Chapter
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply.
36.70A RCW.
n 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:
�r`�' S�L 10/6/25
Date
Environ. Health:
This form may be scanned and available for public view at www.co.mason.wa.us. I've
of