HomeMy WebLinkAboutWAT2026-00100 - WAT Application - 6/8/2026 WAT 2026;QO100
MASON CUNTY 415,WA 98584
Shelton,WA,98584
Shelton:360-427-96.70;Ext.400
Public Health & Human Services Belfair:360.275-4467,Bxt.400
Application for Determination of Water Adequacy
Instructions
1. Complete.,Part No determination can be made until Part 1 Is fully completed.
2. Complete only the portion of Part 2 applying to the type of wafer.connectiorlulilized i
3. Submit completed appficatiorr withany required attachments for review.
4. An approved building site :Ian mustaccómpay this application.'
Part 1: Applicant/Parcel Identification
Nameeppiicant: Date:
ailing Ad ss 5i�,r��4)"" G p 5/3v'__________________Phone: - �/S -/ 3
Parcel Number: /S .G o
Type of Water System Reason for Application
IN Public/Community Water System(2 or more W Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water
O Other(explain) ❑ Qther(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
Name of Water System: $ � ' H '
Water Facility Inventory(WFI)Number: (.pC? — Q (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.
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: ci owneiic,t. uAtvM
This water system Is able and willing to provide water to th (these)connection(s)without exceeding the
limits of the water system orany limits set by state and local regulation.
Print Name of Water System Manager, I ' flStfl Phone d �2l -073
Signature of Water System Manager DateJ2. 2_t
This form may be scanned and available-for public view at www.masoncouniywa.gov
J:\EH Donna\Drinking Witter • Revised 05108/2024 Pugs 1 of 2
Group B Water Systems
.. I
❑ 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 apd.
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.
___._l:L_.Satisfactory_bacterialogical est dth'in..iasLy.ear.4attach_to application.)__._
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)
l Satisfactory Determination:
This determination"does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future;or guaranteecompliance.with'all applicable WDOE water reso.urce.regulations. j
Recommended approval:indicates requirements of Sanitary':Coda,Title"6,Chapter.8;6t3.040=Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management-requirements`may.apply. Chapter
36.70A RCW
ti d' Unsatisfactory Determination
rY.
rm natfcari:�`�
Applicant's water supplydoes not:appear.adequateto meet the deeds of its intended Use for the following
PP .
reason(s): K i
Reviewer's Signature's
Environ. Health: .: .. 'Date...,. 6I8/22 -
This form may be scanned and available for public view at www.masoncountywa.gov
Paget oft