HomeMy WebLinkAboutWAT2023-00009 - WAT Application - 3/16/2022 WAT 20217 - 000o 9
MASON COUNTY ao N.6 street
COMMUNITY Shelton,WA 98584
r1 TY SERVICES Shelton:360-427-9670,Ext.400
�`••; 6uildui .Planning,Environmental Health.Community Health Belfair:360-275-4467,Ext.400
Elm:360-482-5269,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.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification 5P c
Name on Applicant: -j_a_c_ODbert Date:
03.16.2022
Mailing Address: 3139 Donnely Rd SE Olympia.WA 98501 Phone: 619-674-6188
Parcel Number: 22211-51-01025
Type of Water System Reason for Application
Public/Community Water System (2 or more ti
connections) Building permit ak-i 2423 vWz.(v
❑ Individual water source (one connection), ❑ Division of land:
#of Parcels? SPL
0 Well
❑ Spring/surface water 0 Boundary line adjustment
0 Other(explain) 0 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 APPROVED
Complete the section appropriate for the type of water connection being evaluated: JAN 2 4 2023 JTe
Public Water System MASON COUNTY ENVIRONMENTAL HEALTE
Name of Water System: Pleasant Cove
Water Facility Inventory(WFI) Number: 67800N (write"none"for two-party)
15/ I am the manager of this water system.The water system has been approved for 41 services_There
are presently 28 connection(s) in use.This will be the 29 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 Cassandra Kabela N �A1 Sne6�
Phone 360-876-0958 X117
Signature of Water System Manager (. ,Z,La_ Date 03.16.2022
This form may be scanned and available for public view at www.co.mason.wa.us.
I:\EH Forms\Drinking Water
Revised 427202 t
5 ram
Return To 2179892 MASON CO WA
0 / 222 111Il25 A EL
111nillNl2/< 4PePr 111111111111111111liilIIIIIIIII 1111lhllllllll
3/3 9 bo,.m.e.ay
a,,p4",4' luig ?1 /
Grantor(s): (1) ' L, r-i • Gt )�`) w1— (2)
Grantee(s): (1) PUBLIC
�
Legal Description (Abbreviated form:i.e. lot, block,plat or section, township, range)
(1) iZ v- ' , i?t= 3 V u 1 - ` (sewage system, portion of)
(2) A_ << (Po (structure)
Assessor's Tax Parcel: Sec' l i -TW P 2.2. 12 Z_
(1) 1 ? - > I - I I' L (sewage system, portion of)
(2) ► ' - J i _ i L .?
i_..l (structure)
DECLARATION OF COVENANT FOR ON-SITE SEWAGE SYSTEM
I (We) the undersigned grantor(s) hereby declare this covenant and place same on record
and herein, am (are) the owner(s) in fee simple of(an interest in) the described real estate
above under Legal Description (1) and Assessors Tax Parcel (1) situated in Mason
County, State of Washington; which the grantor(s) owns and operates portions of an on-site
sewage system and drainfield or repair area that serves a structure located on the described
real estate under Legal Description (2) and Assessors Tax Parcel (2) situated in Mason
County, State of Washington; and the grantor(s) is (are) required to maintain the on-site
sewage system in such a manner to facilitate treatment and disposal of the effluent. It is the
purpose of these grants and covenants to allow easements for placement and access and to
prevent certain practices that may have significant adverse impacts to the function of the on-
site sewage system.
NOW, THEREFORE, the grantor(s)agree(s) and covenant(s) that said grantor(s), his (her)
(their) heirs, successors and assigns will allow a utility easement for the use and purpose of
conveying sewage from one parcel to the other, to allow an easement for the purpose of
maintaining or repairing the on-site sewage system and appurtenances thereto within 10 feet
of any portion of the sewage system and to prevent practices not consistent with state and
local regulations in this area.
Page 1 of 2
These covenants shall run with the land and shall be binding to all parties having or acquiring
any right, title, or interest in the land described herein or any part thereof, and shall inure to
the benefits of each owner thereof.
Dated on this /. day of r1.n zI , 20 .Z
Signature of Gcantor(s):
(1) = r� , , (2)
State of Washington )
County of Mason )
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this=day of i\.�
, 20..E ,
personally appeared
signer of the above instrument, and acknowledged that he (she) (they) signed it nown to be
GIVEN under my hand and official seal the day and year last above written.
NICHOLAS MOUHTEROS , of ` z
Notary Public in and for the State Washington,
;NOTARY PUBLIC##2097965 residing at , ; �. - _
STATE OF WASHINGTON , My commission expires: 5 /;=, j
i COMMISSION EXPIRES
SEPTEMBER 19,2023
Page 2 of 2