HomeMy WebLinkAboutWAT Application - 4/7/2026 WAT -
A 415 Sheet
COUNTY Shelton,WA 98584
Shelton:360-427-9670 Ext.400
Public Health & Human Services Belfair:360-275-4467,Ext.400
Application for Determination of Water Adequacy
Instructions
I Complete Part 1. No determination can be made until Part I 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 buildingsite plan mustaccompany this application.
Part 1: Applicant/ Parcel Identification
Name of Applicant: Robert Wagstaff Date: 04/07/2026
Mailing Address: 7407 39th CT SE 98503 Phone: 425 501 2329
Parcel Number: 22003 4 - 1QQ73
Type of Water System Reason for Application
'Public/Community Water System (2 or more 0 Building permit
connections) 0 Division of land:
❑ 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.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: SW VC//S iy e,l
Water Facility Inventory(WFI) Number: YVJVIfi (write"none"for two-party)
C I am the manager of this water system.The water system has been approved for 2- services.There
are presently I connection(s) in use.This will be the 2_ 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 state and local regulation.
Print Name of Water System Manager A ! -�S Phon(2 S 3) '2"'( fz-
Signature of Water System Manager 4- Date =e_i
This form may be scanned and available for public view at www.masoncountywa.gov
J:\EH Foims\Drinking Water Revised 05/08/2024 Page 1 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 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 within last year(attach to application).
Individual Spring/Surface Water
0 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 _) T
This determination does not addressadequacy of the distribution system,guarantee art adequate supply of
water indefinitely m the future or guarantee compliance with all applicable WDOE wafer resource regulations,
Recommended approval indicates requirements of Sanitary Code,Title 6 Chapter 6 68 040 Determination of
Adequacy for 13yJldmg Permits are satisfied Additional Growth Management requirements may apfply Chapter.
36 70A RC1N
ti
LI Unsatisfactory Determination
Applicants water supply does not appear adequate to meet the needs its Intended Use for the following
reason(s) x
_ Y
Reviewers:Signatures
Environ. Health: bate
This form may be scanned and available for public view at www.masoncountywa.gov
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