HomeMy WebLinkAboutWAT2026-00023 - WAT Application - 2/3/2026 WAT VV-¢r`2-0ZG - 00013
<4 415 N.6h Street,hre,--.1 MASON COUNTY Sliclton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
pi Belfair:360-275-4467,Ext.400
Building Planning Environmental Health,Community Health Einia 360-482-5269,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 on Applicant: Reed Griffin Date: 01/30/2026
Mailing Address: 141 old Schoolhouse Rd.Sequim WA 953 Phone: 3604604644
Parcel Number: 42329-50-00172 Division-block-lot: DIVISION 1 LOT 172
Type of Water System Reason for Application
12) Public/Community Water System (2 or more 0 Building permit G)97,,p(04.- 000BZ
connections) O Division of land:
O Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ 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. Signature Ree Gri f flh
Part 2: Water Connection Information Email Address rjgriff25@gmal;com
Complete the:section appropriate for the type.of water connection being evaluated:
Public Water System
Name of Water System: LAKE CUSHMAN SYSTEM 5
Water Facility Inventory(WFI)Number: 035290 (write"none"for two-party) i.
O I am the manager of this water system.The water system has been approved forlervices.There
are presently connection(s)in use. This will be the connection.
Di l.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: N/A
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 JESSE MATHEWS Phone 360-877-9668
Signature of Water System Manager k2, N,6,..>,,,.,A,.r; Date 02/03/2026
This form may be scanned and available for public view at www.co.mason.wa.us.
J:1EH Forms\Drinking Water Revised 4/27/2021
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 (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14. 15 16 22_
Water use or limitation recorded N/A Yes
Well Drilled Date
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;andfor
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant
• s
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.
:1 Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
rQ-, Reviewer's Signatures:
Environ. Health: ( IN.Me( nvi Date 3t q fu
This form may be scanned and available for public view at www.co.mason.wa.us.
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