HomeMy WebLinkAboutWAT2025-00215 - WAT Application - 3/17/2025 V6.)/1/4N/SCIN („2,r„, ,, 1
WAT U' L,,� - i!(e ri1 Z,
. MASON
J�ASO N COUNTY 415 on,W �' 8584
��f treet
Shelton,N.
6 98584
4 , Shelton:360-427-9670,Ext.400
.aT .P Public Health & Human Services Belftir: 360-275-4467,Ext.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 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.
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Part 1: Applicant/ Parcel Identification
Name of Applicant: Kamin Properties LLC Date: .7.2025
Mailing Address: 500 SE Cole RD Phone: 360.239.6788
Parcel Number: 32007-14-90011
Type of Water System Reason for Application
4 ❑ Public/Community Water System (2 or more El Building permit CO in Zv 2.5 •00 IOC)
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
O Well 0 Boundary line adjustment
O Spring/surface water ❑ Other(explain)
❑ Other (explain)
0 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: City of Shelton
Water Facility Inventory (WFI) Number: 78170N (write "none"for two-party)
18) I am the manager of this water system. The water system has been approved for 2 services. There
are presently unspecified connection(s) in use. This will be the unspecified connection.
❑ 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)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 Jay Harris Phone 360-432-5125
rl
Signature of Water System Manager ..1 - t r ! //" 1 �
,� Date '/--7 / l
j' (.1 /f r C' .
This form may be scanned and Ivailable for public view at www.masoncountywa.gov
J:\EH Fonns\Drinking Water Revised 05/0W2024 Page I of 2
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
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 tf 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
O WDOE permit(attach to application)
O 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.
Author of Statement Date
Relationship to Applicant
I . •
Part 3: Mason County Community Services Evaluation (staff use•
only)
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This dekerrntna#fon;dgds ridt,address:adequacy ofihedlatribut(on 8ystem,.gusraritee-an adequate supp y of
::water`(hdefinitoly in,the f>,♦1~iire,pr gusrrantee.compliance wlth:all epplleable,WDQg water resource regulst1pns ?r~::
�`:', Reciofrirnerided apprWVal:Ind lOt tes rem
(equlen s of Sanitary CQdQ,,Title Q;Chapter:.6,68040.;IDetermIn8tl n,Qt''.._.-;
yAdequacy f.4P�ulldfng permits era aatlsfied: Addltjohel.Crovyth JVten�gerriaot requlCerllQrst$
r. y apply..,: iappter:.
'$6.70A ikcw, ": 4- f:,,a is•.(. }: f.'.
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Environ. Health: ua e
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of2