HomeMy WebLinkAboutWAT Application - 1/22/2024 wAT
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Application for Determination of Water Adequacy
Instructions
t_ 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.
4. An approved budding site plan must a,,,neqny this appk2bDn.
Part 1: Applicant(Parcel Identification
Name on Applicant Deter y 2.2-24 —
Mailing Address: �.�,,�� L.. I 'l I nun L Phone: 3 LOD .01-3 ' ! `'r 3
Parcel Number: or+r-vrvrL- WA gt'J..C4 aacoq - 5i - W6() 9 .
Type of Water System Reason for Application
❑ Public/Community Water System(2 or mane ❑ Buildingpennit 13LD31y4-00055
�.r connections) ❑ Division of land
p Individual water source(one conneciii #or Parcels? SPL
,> . Well ❑ Boundary line adjustment
❑ Spdng/surface water ❑ Ot in)
❑ Other(explain)
Replacement r Remodel(please indicate name
If you have more than one residence connected o wa er system below i applicable-no
to this well, check the PuWiNCommuniy 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: _
Water Facility Inventory(WFI)Number
(write"none'for two-party)
❑ 1 am the manager of this water system.The crater system has been approved for services.
There are presently connections),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 fire time). Please indicate on the following line the nature
of this change:
This water system is able and wing lu provide water to tlt5(these)connection(s)without exceeding
the limits M the water system or any limits set by stale and local regulation.
Sigraeue of Water System Manager Date
This fmm may be scanned and available for public view at vwrwAo mason wan us.
Individual Water Well
❑ Water well report(attached m application). Deptlr it
❑ Well capacity Test(attached to application) apm ape.
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 dsw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area(WIM)
Development within which WRIA http'//ais.co.mosm.wa.us/plaMim 14_15 16 22_
Water use or limitation recorded................................... WA Yes
Well Drilled ..................._......................._._..._._...._. Date
Individual Spri glSurlace Water
❑ W DOE 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)
Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefirurely in the ferrite,or guarantee cornpicrce with all applicable WDOE water resource regulations.
Recanmerided approval irs icoms requirenc»6 of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building PemYts are satisfied. Additional Crown Mariagcncnt requirements may apply. Chapter
36.70A RGW-
_ Unsatisfactory Determination:
Applicants water&pply does not appear adequate W meet the needs of its brtended use for the following
reasm(s).
�yy� Reviewer's Signatures:
Envimn. Health: �? � r " ' Data
This faro may be scanned and avatable for public view at www.ca.maaon.wa.ua.
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