HomeMy WebLinkAboutWAT2026-00020 - WAT Application - 2/25/2026 /
i
WAT 2026-0Q020
-‘,01'--,;Fc,yl; 415 N.611'Street
1 , MASON COUNTY Shelton,WA 98584
i COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
i�,:_, 1(�i `s.1 : , BeWain 360-275-4467,Ext.400 '
1t'�`•:. .1. Elms:360-482-5269,Ext.400 •
?� Building, Community
Application for Determination of Water Adequacy
Instructions • , _
1. Complete Part 1. No determination can be made until Part 1 Is fullv.completed. .
2. Complete only the portion of Part 2 applying td 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: tee-ICC 1%4 S 7" Date: if� 2. -26,
Mailing Address: Pa goA 121 1bodyp i way Phone: 4#42)<^Z 4 ' /4 9 3
Parcel Number: 1/02./4 6-7... O" if 3 DIV 12 LOT 113
20 N KINGSWAY N
Type of Water System .. . Reason for Application
t ' Public/Community Water System (2 or more geBuilding•permit
connections) O Division of land:
O Individual water source(one connection), #of Parcels? SPL
❑ Well O Boundary line adjustment
❑ Spring/surface water O Other(explain)
O 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 Wafer 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: LAKE CUSHMAN SYSTEM 5
Water Facility Inventory(WFI).Number: 035290 (write"none"for two-party)
O I am the manager of this water system.The water system has been approved for services.There
are presently connection(s)in use.This will be the connection. •
XI 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: Putting a manufactured home on loth
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 360-877-29668
Signature of Water System Manager Jt —____....__Date___01/26J2026.....,___. ...._.•.
9 Y g ,� rn�u,�...u..,,1¢znwOa.}}YP}Tj -
This form may be scanned and available for public view at www.co.mason,wa.us.
J:\6H Forms\Drinking Water • Revised 4/27/2021
•
Individual Water Well
O 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.
O Satisfactory bacteriological test(attach to application).
• Water Resource Inventory Area (WRIA)
•
Development within which WRIA http://gis.co,mason.wa.us/planninq 14 ;._ 15__-,16_22_
Water use or limitation recorded . N/A Yes
Well Drilled Date • •
•
Individual Spring/Surface Water
❑ WDOE permit(attach to application) •
O Method of disinfection
O I have reason to believe that this water source cap 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)
ti mrnatlont facto D star
C� Sas
Of
the distribution s stem uarantee an.,ad:equate• supply of„:.•:.
This defermtnatlon does not address adequacy f . y .9 .
water indefinitely In the future,or.guarantee compliance with all applicable WDOE Water resource re ulatl6ns':" .
Recommended approval indicates:requirements;of Sanitary Cndej,.1 le hap
6,Cter:G 66 0404Determtnation of
•Adequacy for Building Permits are satisfied..Additional Growth Management requlrements'may sppl.y Chapter
36.. .0A ROW. ;
❑
na io Unsatisfactory Dete n �.
•
•
Applicant's water.:supply does not appear adequate to"Meet the:needs of:its Intended.use for.the foltawirrg
:reason(s)
. . ....:...
Reviewrer'.sg:Si natures:
. :.. . ..:. .. :.•Environ. Health: :Date . `2/25/26
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of2