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Home My WebLink AboutWAT2020-00162 - WAT Application - 5/6/2020 WAT Z0_0 - 00[ L MASON COUNTY COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health 415 N 6th Street,Bldg 8,Shelton WA 98584, RECEIVE D Shelton:(360)427-9670 ext 400 s Belfair:(360)275-4467 ext 400 i Elma:(360)482-5269 ext 400 FAX(360)427-7787 JUL 0 q 71 Application for Determination of Water Adequacy 615 W. Alder Str€' °t 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. 4. An approved building site plan must accompany this application. Part 1: Applicant/Parcel Identification Name on Applicant:VCr `C� Date: IJ•(,�•aCf Mailing Address: 1GU/�c'lnp_ J)k. E(of -( t (,t Parcel Number: 233i '-53• olf Type of Water System Reason for Application Public/Community Water System (2 or more E /Building permit connections) 0 Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ Other(explain) 0 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: L.�L�--�C i�� LL (g__ Water Facility Inventory(WFI)Number: i t-�--C) ' a (write"none"for two-party) tt�I am the manager of is w er system.The water system has been a pved for_lbservices. There are presently connection(s)in use.This will be the connection. 0 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 Ii its set by state and local regulation. Signature of Water System Manager Date (2-k) This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 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 http://gis.co.mason.wa.us/planning 14_ 15_ 16_22_ Water use or limitation recorded................................... N/A_____N/A Yes Well Drilled ............................................................... Date Individual Spring/Surface Water O WDOE permit(attach to application) O 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 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-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 36.70A RCW. ❑ 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: ti�'ln�l ' Date �Z CSD Director: Date 2of2 ASON COUNTY COMMUNITY SERVICES Permit No:SIG{202® - OD 5Zcj MIT ASSISTANCE CENTER: •BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL E VA - rM E/r 615 W.Alder Street,Shelton,WA 98584 o Z t_ d L. I V Phone Shelton:(360)427-9670 ext. 352•Fax:(360)427-7798 Phone Be/fair:(360)275-4467•Phone Elma:(360)482-5269 BUILDING PERMIT APPLICATION PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION: NAME: DAVID BERGLUND NAME: "cl. %1J (Lit'fW1 c(n ES. MAILING ADDRESS: 628 N. 6th STREET MAILIN ADDRESS: ciC° t I S 4c_ _ CITY: SHELTON STATE: ZIP: $4 CITY:-!5H___ W� STATE: LV ZIP: PHONE#l: 253 - 549-6310 PHONE: CELL: PHONE#2: 361) - 426-7274 EMAIL : EMAIL: daveb@activeconstruction.com L&I REG# C( Oda c11" EXP. l ?l P �. PRIMARY CONTACT: OWNER[ CONTRACTOR❑ OTHER❑ NAME DAVID BERGLUND EMAIL dave activeconstruction.com MAILING ADDRESS 628 N. 6th STREET CITY SHELTON STATE WA ZIP .98584 PHONE 360 426-7274 CELL 253 - 549-6310 PARCEL INFORMATION: PARCEL NUMBER(12 Digit Number) 320030002000 ZONING LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT SITE ADDRESS 61 SANDPIPER LANE CITY SHELTON DIRECTIONS TO SITE ADDRESS Take hwy 3 north out of town. Bayshore Community is on the right about 2 miles north of town IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NO IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check all that apply): SALTWATER[ J LAKE ❑ RIVER/CREEK ❑ POND ❑ WETLAND ❑ SEASONAL RUNOFF ❑ STREAM ❑ TYPE OF WORK: NEW X❑ ADDITION ❑ ALTERATION ❑ REPAIR❑ OTHER ❑ USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc.) RESIDENCE IS USE: PRIMARY ® SEASONAL ❑ NUMBER OF BEDROOMS 2 NUMBER OF BATHROOMS 2.5 HEATED STRUCTURE? YES (Whole Bldg) N YES (Part[sJ of Bldg) ❑ NO ❑ DESCRIBE WORK NEW 2 STORY RESIDENCE SQUARE FOOTAGE: (propose+existing) 1ST FLOOR 1,480 sq. ft. 2ND FLOOR 754 sq.ft. 3RD FLOOR 0 sq. ft. BASEMENT 0 sq. ft. DECK 230 sq. ft. COVERED DECK NA sq.ft. STORAGE NA sq. ft. OTHER sq. ft. GARAGE 390 sq. ft. Attached N Detached❑ CARPORT sq. ft. Attached❑ Detached❑ MANUFACTURED HOME INFORMATION: *4 COP! AN REQUIRED* MAKE MODEL YEAR LENGTH WIILLU BATHS SERIAL NUMBER ENVIRONMENTAL HEALTH: SEWAGE/SEWER SOURCE: SEPTIC SEWER❑ / NEW ❑ EXISTING N PLUMBING IN STRUCTURE? YES NO ❑ If yes, attach completed Water Adequacy Form PERIMETER/FOUNDATION DRAINS PROPOSED? YES ❑ NON EXISTING SQ.FT. EXISTING BEDROOMS 0 PROPOSED BEDROOMS 2 TOTAL BEDROOMS 2 OWNER acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is by signature below. I declare that I am the owner and I further declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary parties, including any easement holder or parties of interest regarding this project. The owner or legal representative, represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s)for review and inspection. This permit/application becomes null&void if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINU N OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATI F 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED. (MASON COUNTY CODE 14.08.42) ignature of ER(Must b signed by the OWNER) Date DEPARTMENT REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS BUILDING DEPARTMENT PLANNING DEPARTMENT FIRE MARSHAL PUBLIC HEALTH $ fry C2 / \ RECEIVED 615 W. Alder Street .1 3�'(rls�o�1- Lien- --- c- ENVIRONMENTAL TO WA-3 HEALTH NDP'p t !j N 650 56A �R lqN� �S 11"W I I NS�� TO BAYSHORE DRIVE 1d 2020 oc� 25 1 so., M - ��-rY�o al0 1 PROPERTY LINE PROPOSED ROOF OUTLINE I i I I i i PROPOSED BUILDING OUTLINE i I b � j o/ 5 PROPOSED TWO Iw 51 I STORY SINGLE FAMILY RESIDENCE Io IC 10 I i I I j I I I `o I-----------1 I 1 1 t APPROVED :u A ' AUG 282020 z 2'-0"TYPICAL ROOF 1 OVERHANG&GUITER i 1 I MASON C0U Y ENVIR0NMENYAL HEALTH 1 1 1 LYC ROOF OVERHANG OF ADJACENT PROPERTY L--- 1---- -- ----------- --- - 7'- R �� F 1 —_ 21.79 __ I `I' S 70°49' 55"E �9 spop O?, �7F - - - - - - - - - - - 0 8 16' 1 SITE PLAN CVR 1/16"= 1 -0" SCALE: 1/1 6" UTH PLAN