HomeMy WebLinkAboutWAT2025-00196 WATER ADEQUACY - WAT Application - 10/23/2025 0 MASON COUNTY WAT2025-00196
COMMUNITY SERVICES
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415 N 6e Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 . Belfair.((30)))5—427-TT87xt 400 Elma:(360)462-6269 ext 400
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Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part type f1 Is f idly connection utilized.d.
2. Complete only the portion of Part 2 applying to
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 1)k,)w . , Aa;,..kA Date: ?' I ask 9-5-
Malting Address: +-I C.! G Nu: �ULL.yRL7 Phone: . .i, U fv.?,G �' t �ZaNNAe..c Cs..� same. eve_. l.3.
Parcel Number:
a'a.r 1-1 ' 7..1 ct c,c 3..3
Type of Water System Reason for Application
1 ubiic/Community Water System(2 or more Be Building permit .17)1(1 2091'5
connections) 0 Division of land:
0 Individual water source(one connection), #of Parcels? SPL
i ❑ Well ❑ Boundary tine adjustment
❑ Spring/surface water ❑ Other(explain)
0 Other(explain) ❑ Replacement or Remodel(please indicate name
tf 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: Q uy 02►- W
Water Facility Inventory(WFI)Number: 0 561 $ 1?a
(write"none`for two-party)
id I am the manager of this water system.The water system has been aporoved for b services.
There are presently 3,. connection(s)in use.This will be the L{ connection.
II II e 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: F%.L L TS Oh 't
rj.
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.
Signature of Water System Manager OovM. ck, 4r n4.nikr. Date 7 . 1 `i 1
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Individual Water Well
❑ Water well report(attached to application). Depth ft.
0 Well capacity Test(attached to application) qpm gpd•
The well driller often performs well capacity testa at the time the well is constructed. Results from
those tests are noted an the water well report. Results from these teats 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.
11 Satisfactory bacteriological test(attach to application).
:.:. ---
Water Resource inventory Area(WRIA)
Development within which WR1A tit ip://ciis co mas4nn wa.u5/planning 14 15 18 2 ,,..,
Water use or limitation recorded N/A_____Yes •
Well Drilled Data
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
O Method of disinfection
0 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 �II
e
•
Part 3: Mason County CommunityServlces Evaluation (staff use onliy)
3 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 W DOE water resource regulations.
Recommended approval Indicates requirements of Sanitary Code,Tills 8,Chapter 6.68.040-Determination of • II
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.7OA RCW. Satisfactory BacT 5/12/25 with DOH
El Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of Its Intended use for the following
reason(s).
c Reviewer's Signatures:
cZAltrV ( 10/23/25
• Environ. Health: Date
PrintedgMtPlason County DMS Date 2of2
Printed from Masnn r:sntnty in c