HomeMy WebLinkAboutWAT2025-00246 - WAT Application - 12/29/2025 WAT 2025-00246
MASON '"� 415Street84
j Shelton,,WA 988845
1. Shelton:360-427-9670,Ext.400
4 -: Public Health & Human Services Bellair360-275-4467,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.
Part 1: Applicant/ Parcel Identification
Name of Applicant: Waste Connections,Inc. Date: 29 December 2025
Mailing Address: 81 East Wilburs Way,Shelton,WA 98584 Phone: 253-282-5584
Parcel Number: 320053390070
Type of Water System Reason for Application
Public/Community Water System (2 or more i ( Building permit
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
0 Spring/surface water 0 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: C.(1-1 of Shl 6117,NI
Water Facility Inventory(WFI) Number: 7431-10 1J (write"none"for two-party)
tl I am the manager of this water system.The water system has been approved for 2- services.There
are presently ur(5Ptcti,cD connection(s)in use.This will be the oat SPEah O 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)connection(s)without exceeding the
limits of the water system or any limits set by stat and loc I regulation.
Print Name of Water System Manager , a M S Phone 3a, gip 105-3
Signature of Water System Manager Date 1,1f2 ?, ,..:
This form may be scanned and available for public view at www.masoncountywa.gov
J:\EH Forms\Drinking Water Revised(15/08/2024 Page 1 of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
O Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm qpd.
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.
O 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)
g .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 6.88 040-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
reasons)
Reviewer's Signatures:
• VJ OW`14- • 12/29/ 5
Environ.-Health:, Date
This form may be scanned and available for public view at www.masoncountywa.gov
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