HomeMy WebLinkAboutWAT2026-00108 - WAT Application - 6/15/2026 F 1 '_ 2028-00,108 i
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MASON COUNTY 27-9670,Ext.A X8400
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Application for Oet rtnlnation of Water Adequacy
Part i�lo d ter ination cen be rr ada u,0111 Pert is full e, m tete ,Part( Only the rtii n of Pa 2 applying the pe'tif water c rlectl r ut i 3
t pldetien," +ith'any required attachments tc�r rvasv�r.
° n a o °k ldlr site la"Jm—ust accom an this a lication.
I't Applicant!P trcel identification
on pllcantf ate:
a . . ,address: m Phone: "
Parcel Number ,. L4"
°°
Type of Ws t ' ' Reason for Application
Public mmunity Water System(2 or more Building permit
connecfa s Division of land:,
O lndividuo water source(one connection), #of Parcels? SPL
L We O Boundary line adjustment
" pringt'surlace Water . °
- r .13 tatp . . O Other(explain)
O Replacement or Remodel(please indicate ram
If you have more onerresrdenee connected of water system below if;applicable—no
. ,ts wellb,chec the Public/Community Water signature°required(
i Stem box
artWater Connection Infornnation
Con'plete the section appropriate for the type of water connection being evaluated:
}
Public Water System F
tarnewate system
in e tort'(WFf}Number: ,
(write fort ar
t.am t tea r f t aW y'atem;The water sy tern has pproved for , servl�.There
preenUy f4connecqn ),in use.This will be the cortraectiort,
(arty the monaer otmtt tSTLThis connectjøn gull(be to upgfad or gang dnnge the use of an axi tirt
orrr nOn ltt (Le.; re reatlonal to full time),? °ndloate on the:fotlo ln line the natw'e of
hy$chonpø.
bls war systernl e .la and willih to provide water to thIs (th e'e)co rneollon(a)without e ceedittr the
limit rat the War , teiT or any lln:tlla, et by state pod is ai ie ian
Pant Name of fad ' ar't en 6r 'hone
tgnature of Water System lr :Dad
Tli fc�i nnt Od avaabe for`
ubflc view at rtr ctJmasa�tt waus
1
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
O WDOE permit(attach to application)
O Method of disinfection
O 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 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.
El Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: Date 6/15/26
This form may be scanned and available for public view at www.masoncountywa.gov
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