HomeMy WebLinkAboutWAT2026-00193 - WAT Application - 8/18/2026 T 2026-0 .193
415 N.ryth Street
MASON COUNTFY sllellot,_ t A 9855:1
k Shelton:361}-1 7 9670, I'At.400
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Application for Determinaton o Wati r Adeauacy
1. Complete Part 1. No determination can be made until Part 1 is fully com feted,
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 Ian must accornpay this appiica₹ion.
Part 1: AppllcartJ G ar ca dentfic2ion;
Name on Applicant: 11-Ae:
Mailing Address: 3(A) E >l y 5f-'lc(. v Tg��. Phone: 3(gq"
Parcel Number: 24 Z 4 4 -- —
Type of Water System Reason for Application
Public/Community Water System (2 or more n, Building permit
connections) O Division of land:
O Individual water source (one connection), It of Parcels? SIP
O Well O Boundary line adjustment
O Spring/surface water El Other(explain)
O Other(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 PubliclCommunity Water signature required)
System box.
Part 2: rat :t , °any c'L ,n &'mation
Complete the section appropriate for the type of water connection being evaluated:
Pubiic Water System
Name of Water System: . =
Water Facility Inventory (WFI) Number:
(write "none" for two-party)
❑ I am the manager of this water system. The water system has been approved for__ ___services.
There are presently 1 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:
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.
Signature of Water System Manager G r� Date -,2 A
This form may be scanned and availal.
JAH E Pttrmsl]hin!titts 1Vatrr
Individual Water Well
�" Water we t attached to application). Depth , a __ft.
Well capacity Test(attached to a ion) pm ,_gpd.
The well driller often performs well ca ests at the ae well is constructed. Results from
these tests are noted on th r well report. Results from these grill be accepted. If the water
well report Cann cated by the applicant or if the water well report does i e a capacity test,
a well s y test, which provides stabilization of draw-down and recovery data, must ruled
a licensed contractor.
54- Satisfactory bacteriological test(attach to application). Satisfactory BacT for Group B well
on DOH website is 12/17/25.
Water Resource Inventory Area (WRIA)
Development within which WRIA 14_ 15 1622
Water use or limitation recorded N/A_____Yes
WellDrilled ............................................................... Date
Irt ater
Cf 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
art 3: Mason County Community ServicesEvaluation (staff u e y)
ki 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 6.68040-Determination o₹
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
i Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reasons)_ __ _����_
Reviewer's Signatures:
9/11/2026
LEnViron. Health: Date
This form may be scanned and available for public view at wrwanr.camn.wa,us,
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