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HomeMy WebLinkAboutWAT2025-00185 - WAT Application - 10/28/2025 • jWATQOQI5 I ems, MASON a I s N.G^Strcct COUNTY Siicltan,WA 98584 Shelton:360•427-9670,list.400 -.--y�,. — Public Health & Human Services Belfoir;36I)275.4467,Fxt.400 Application for Determination of Water Adequacy • 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 typo of water connection utilized. 3. Submit completed application with any required attachments for review. i 4. An approved building site plan must accompany this application. Part 1: Applicant/ Parcel Identification Name of Applicant: n I my Qb\bed � Date: / ailemaC Malling Address: OF28 an' i`j W___Phone: 0.5 „�7 Parcel Number: if ab-b6.- oy ObO 19© Type of Water System Reason for Ap Ilcati� Oon j i']� Public/Community Water System(2 or more Building permit v�.laa ! `r connections) 0 Division of land: ❑ Individual water source(one connection), tt of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ Other(explain) ❑ 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 IN Z- prrf Complete the section appropriate for the type of water connection being evaluated: WE t' zc. do ofvV Public Water System (� "i/ Name of Water System: W f' [ 1 — �L�3� 1 �.1 Water Facility Inventory(WFI)Number: N ) '\ _ (write"none'for two-party) I am the manager of this water system.The water system has burn approved for 2- services.There are presently t connection(s)in use.This will be the 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)connectlon(s)without exceeding the limits of the water system or any limits set by state and localregulation. Print Name of Water System Manager MiCkli/ /t"yM- "` /i'1 Phone(X 7)419 2_ 38 Signature of Water System Manager Date Ze 4.5— This form may be scanned and available forprrbl c view at www.masoncountvwa.gov ):\rill Puun\Drinking Willer Reviscd05/08/2024 Page I of2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth Y V ft. 6 ? CO gpd.8717/?0l(I Well capacity Test(attached to application) �t the time thegwe I is constructed. Results from The well driller often performs well capacity tests 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. t ✓ Satisfactory bacteriological test within last year(attach to application). ((J(7 'j7oi 7 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) ySatisfactory 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. Li Unsatisfactory Determination: `// Applicant's water supply does not appear adequate to meet the needs of its intended use f4ttitirfpllowing t? k.. -------- Reviewer's Signatures: rLv �/4� Environ. Health: Date1 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2