HomeMy WebLinkAboutWAT2026-00157 - WAT Application - 8/10/2026 WAT 2026-00457
MASON COUNTY si,dm . Wn 9xsx4
Shelton:360-427-9670.Gs.400
Public Health & Human Services Oeli ir360-275-4467. 1-,1.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 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 of Applicant Leah Larsson Date: 5/13/26
Mailing Address'. 607 SE Eaton Blvd, Battle Ground,WA 98604 Phone: 360-912-9521
Parcel Number. 323312190870
Type of Water System Reason for Application
■ Public/Community Water System(2 or more ❑ Building permit
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
O Spring/surface water ❑ Other(explain)
❑ Other (explain)
■ 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: Canal Mutual
Water Facility Inventory (WFI) Number 10999 5 (write .none" for two-party)
❑ 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.
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. Active Connection
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 Brandy Milroy Phone 360-877-5249
Signature of Water System Manager + Date 05113/2026
This form may be scanned and available for public view at www.masoncountVrwa.gov
1 Pain 1'nrrnc Drinking Weer Rr,iced 05;08,2024 Page 1 oft
Group Water Systems
I
❑ Satisfactory bacteriological test within;' st year(attach to application).
Individual Water Well
0 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 Nater well report does not have a capacity test,
a well capacity test, which provides stabilization of dr -down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test within last year(attac to application).
Individual Spring/Si rface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
Cl I have reason to believe that this water source can rovide at least 800 gallons per day; and/or
provides water at a rate of 2 gallons per minute ba xl on the following observations.
Author of Statement Date
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
R Satisfactory Determination:
This determination does not address adequacy of the dis ribution system, guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance ith all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanit ry Code,Title 6, Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional C owth Management requirements may apply. Chapter
36.70A RCW.
Unsatisfactory Detemtination:
Applicants water supply does not appear adequate torn et the needs of its intended use for the following
reason(s).
Sw� Reviewer's Sig latures: 8/10126
Environ. Health. Date
This form may be scanned and available for pull view at www.masoncountywa.gov
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