HomeMy WebLinkAboutWAT2026-00012 - WAT Application - 2/18/2026 WAT 2.O2.(O - 000 1-2..
F 415 N 6"Street
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., g S elton,WA 95 $4
Shel:tl 6 4 7 (11 Ext.400
I Public Health & Human Services Belfair:360-275-4467,Ext.400
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615 W.Alder Street
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: kb i1tab )%t Alt it rv'\ Date:
..5,! VI '�, t o lk'G ,.--b t L4Phone: c[5.4 6,1,
Mailing Address: spy kz. t l,A o. b J 2 (5D �
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Parcel Number: i q 01-Pi •' 0 b�)L�
Type of Water System Reason for Application
qk Public/Community Water System (2 or more O Building permit BLD2026-00060
connections) O Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well O Boundary line adjustment
❑ Spring/surface water O Other(explain)
❑ Other (explain)
O 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 a WEL2025-00032
(314
6�Name of Water System: Ali/4 7P.1'1 - 0 / 00 a o 1 0/ q 6 ��l,J 6 oWater Facility Inventory(WFI) Number: (write"none"for two-party)
I am the manager of this water system. The water system has been approved for ' services.There
'It
are presently J connection(s) in use.This will be the ./ connection.
O 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 40 V A &4' ,v it Phone(,. 4 t-i m' -71-71r;
Signature of Water System Manager ,/% 7,/J Date I I/is /
/
This form may be scanned and available for public view at www.rnasoncountywa.gov
7:`•FHForms\Drinking Water Revised 05;08/2024 Page I oft
Group B Water Systems
l6 Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
163 09/02/2003
Water well report(attached to application). Depth ft.
11.5 >800
`4 Well capacity Test(attached to application) gpm gpd.07/09/2025
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.
1 , Satisfactory bacteriological test within last year(attach to application). 06/07/2025
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 regulatloris
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.88 040 Determination of
Adequacy for Building.PerMite.46-Datigti4 Additional Growth Management sthapt6r :'
36,70A RGW
❑ Unsatisfactory Determination
Applicants water supply does not appear adequate to meet the needs of its Intended use for the following
reasons).::
Eli APPROVED Revie'wer's Signatures:
Environ. Health; Date 2/18/2026
This form may be scanned and available for public view at www.masoncountywa.ctov
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