HomeMy WebLinkAboutWAT2025-00198 - WAT Application - 8/28/2025 MI MASON. COUNTY 4i5r: r<r,Sih...r
�it(li.•n,WA witgd
Public Health & Human Services Nhrii<.„ mti rr r ,„n.I Iix<
Relic. tbn:1% 410.I'itHwi
Application for Determination of Water Adequacy
instructions _
1- teiTar! 1. No determination can be mode until Hart 1 Id f l lY_tXTflwftti -
2. COtnp$stet only the portion of Pert 2 applying to the typo of mew connection utilized
3. Submit completed application with any required ettnchmonte for revtnw,
4. An storeyed building site plan must accom�any this applicnlon — __ . . _. .
Part 1: Applicant/ Parcel Identlflcetlon
Name of Applicant %.,`jet'(''- S.If 1/! Date. c /p2 [1 )
Marling Address. /3/i r,J?r) � 1�Lsoctt Phone• L35J)yo,, '1/ 73
Parcel Number 2 ;677 vc. 9b?roy
I .-1-7. 6tfksrc)
Type of Water System /, Reason for Application
fi/Publiic/Community Water System(2 or more le- Building pormit 13 Id L v ,i 1.4.
connections) I't t)ivih;lon of land
0 individual water source(one connection). ft of Parcels? SPt
0 Weil O Boundary llne adjustment
0 Spring!'surface water 0 tither(explain)
O Other(explain)
17 Replacement or Remodel(please•nd:cate newer-
If you have more Char o-a residence connected of water system below it applicable-no
to this welt.cheat.the Poblicrommunity Water signature required) l"I Elk) 5112.
System boa.
Part 2: Water Connection Information
Complete the sectors aopropnate for the type of water connection being evaluated:
Public Water System
Name of Water System C 6
1 Water Facdty Inventor (WFI)Number ,r4� a 7V , (write"none`for two-party)
I am the manager of this water system.The water system has been approved for (o services Thee
l are presently C connection(s)in use This will be the 2_, connection
i 0 I am the manager of this system.This connection will be to upgrade or change the use of an ex•st:nil
1 connection or<this system(e e-recreational to full time).Please indicate on the following ime thee nature.:f
i this change _This water system is able and wilting to provide water to this(these)connection(s)without eweed ng vie
limits of the wale'system or any limits set by state and local regulation
Print Name of Water System tvlanager , ►1. .. 93\kil-t) Phony 3t�10-B0t-- 37S"
) Signature of Water System Manager.. Date 01 —c-..z'
' • This form may be scanned and available for public view at www.msoncountiywa.gov
Group B Water Systems
N Satisfactory bacteriological test within last year(attach to application). DOH
2/12/25
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 Evaluation (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). •
Reviewer's Signatures:
'wnnti 10/24/25
Environ. Health: Date
This form may be scanned and available for public view at www.masoncountywa.gov
1'age2of2