HomeMy WebLinkAboutWAT2025-00211 WATER ADEQUACY - WAT Application - 10/20/2025 b2 1
WAT 2025-00211
MASON COUNTY 415 N.6th Street
. : Shelton.\vA 98584
/ /7 Kelton:360.427-9670,Ext.400
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L Public Health & Human Services SEP
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Application for Determination of Hater: Acleq cy
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
Migel Anelmo Date: 08/05/2025
Name of Applicant: g 360-508-8696
Mailing Address: PO Box 401,Belfair,WA 98528 Phone:
Parcel Number: 123305200021
Type of Water System Reason for Application
Gil Building permit BLD2025-00944
C9 Public/Community Water System(2 or more D Division of land:
connections)
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
O Other(explain) EC 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: Beards Cove Water Water Facility Inventory
(WFI)Number: (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.
IS7 I am the manager of this system. This connection will be to upgrade or change the use of an existing
connection or);tt is sy tem i.e.: recreational/ to full t\me).PPleeas
Please indicate on the following line the nature of
this change: Q) CL',.0 Q\b \ r
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
Richard Dickinson Phone 360-427-9670 x 652
Signature of Water System Manager ----• -- Date 0-9—c)-9—Z 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 o12
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
thts from
tests
e
we el r tests cre oted on the water well be located by the applicant t o if thle water well these
report doesbnot have accepted.caf the water
apacity test,
well report cannot •
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 Sprin urfa r
❑ WDOE permit(attach to as ! -
CI Method of disinfection
❑ I have reason to believe that water - c n provide at least 800 gallons per day; and/or
provides water at a rate of 2 • •ns per minute based on the following observations.
Author of Statement
Date
Relationship to Applicant
•
•
Part 3: Mason County Community Services Evaluation (staff use only)
X 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.
i] 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: 10/20i25
S W/- Date
Environ. Health:
This form may be scanned and available for public view at www.masoncountywa.gov
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