HomeMy WebLinkAboutWAT2026-00147 - WAT Application - 8/7/2026 AT 2L2± - CCJ_`LI---
MASON COUNTY 1N WA" 8584
Shelton,WA 9R584
.Shelton:360-427-9670,Ext.400
Public Health & Human Services nelfai' 360-275-4467.Ext 400
Application for Determination of Water Adequacy
Instructions
1 Complete Part 1. No determination can be made until Part 1 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.
approved building site plan must accom ap 7/y this application.
Part 1: Applicant/ Parcel Identifica, on 2 / 3 2�
Name of Applicant. j
CG' ri��' TLAIJc- Date lo
g oL -I-` 4�f _ one: zt?
Mailin Address: —
Parcel Number 232 '5D- 31025
Type of Water System Reason for Application
wlc�2& CG 100
PubliclCommunity Water System (2 or more Building permit
connections) ❑ Division of land'.
❑ Individual water source(one connection), #of Parcels?_ SPL
U Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel (please indicate name
of water s stem below if applicable—no
If h have check c than one residence ty cted Y
to this well, 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: union _
Water Facility Inventory(WFI) Number: 51920 W (write"none'for two-party)
Ve' lam the manager of this water system.The water system has been approved for 316 services.There
are presently 267 connection(s) in use. This will be the 268 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: _
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
- -' 07/13/2026
Signature of Water System Manager�i - '� 1� rr( -sn Date
This form maybe scanned and available for public view at www.masoncountywa.qoy
J AEll PoursA Urmklrig Wale' Revised 05!0S021 rune I oft
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
Vficensed
ll report(attached to application). Depth ft.
acity Test(attached to application)_._. .gem gpd.
driller often performs well capacity tests at the time the well is constructed. Results from
ts are rioted on the water well report. Results from these tests will be accepted. If the water
rt cannot be located by the applicant or if the water well report does not have a capacity test,
pacity test, which provides stabilization of draw-down and recovery data, must be performed
a nsed contractor.
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Spring/Surface Water
7nifection-
d/o,]
(attach to application)
ion_
to believe that this water source can provide at least 800 gallons per day; and/orr 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)
Ib 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 6.68.040-0etermioation of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Ii 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 8/7/26
This form may be scanned and available for public view at www masoncountywa.gov
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