HomeMy WebLinkAboutWAT2026-00159 - WAT Application - 7/29/2026 WAT 2026-00159
flk MASON COUNTY
LWW COMMUNITY SERVICES
eulldlnp,Planning,6rvhmmental Hlth,Coinmwlty Health
415 N 6a'Street,Bldg 8,Shelton WA 96584,
Shelton:(360)427-91370 ext 400 i Belfalr
)275-44e7
.44 7 ext 400 Flma:(300)482-5269 ext 400
FAX(360)
Application for Determination of Water Adequacy
Instructions t m_ ,()
1. Complete Part 1. No deter�ta
made until Part 1 is fully completed.
2. Complete only the portion og to the type of water connection utilized.
• 3. Submit completed applicatiquired attachments for review.
4. An a roved building site pm an this a Ilcation.
• Part 1: Applicant/ Parcel Identification
,f Date:
"7 2-7 ZLv
Name on Applican�tj: -�❑)/V�t
Mailing Address: (�2,_(�, Ay`�4' Sf t PhoneC„Z _ G`� 6G
- Parcel Number:
Type of Water System Reason for Application
Public/Community Water System (2 or more 2 Building permit
connections) Division of land:
❑ Individual water source(one connection), It of Parcels?_ SPL
❑ Well 0 Boundary line adjustment
❑ 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: /IA14,41CL Ccnmu,e t, __
Water Facility Inventory(WFI) Number: (/932 O
(write none' for two-party)
❑ I am the manager of thiy,ater system. The water system has been approved fort2e services.
/?here are presently C717 connection(s)In use.This will be the connection.
Sd i am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this sy t m (i.e.: recrgqatlo�al to full time).Please indicate on the following line the nature
of this change: lnnSYrwdL,_
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 ocal regulation.
Signature of Water System Manager
Date
This form may be scanned and available for public view at www.co.fllasOfl.Wa.US.
J:\EWI Fu,ms\Drinking Water Revise 112512018
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.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA bttD://Qis.co.miQP- aU5t 14_15_16_22_
Water use or limitation recorded.... ...... ............ .......... NIA_____ Yes_
WellDrilled .........._................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 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)
t 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 wafer resource regulations.
Recommended approval Indicates requirements of Sanitary Code,Title e,Chapter 6.68.040-Oetermination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
30.70A ROW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of Its intended use for the following
reason(s).
£ f� Reviewer's Signatures:
KTlte S 8/10/26
Environ. Health: Date
CSD Director: bate