HomeMy WebLinkAboutWAT2023-00058 - WAT Application - 3/13/2023 ENVIRONMENTAL :_, ,Fi 3
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HEALTH
' q i"I''r 415 N.6"'Street
MASON COUNTY F I—Or Shelton,WA 98584
COMMUNITY SERVICES �1 ..rr•l Shelton:360-427-9670,Ext.400
OAR 1 J L'eLJ Belfair:360-275-4467,Ext.400
Building,Planning,Environmental Health,Community Health Elma:360-482-5269,Ext.400
615 W. Alder Street
Application for Determination of Water Adequacy
Instructions
i'ciii i. No i3elelii1111di1Ur1 can be made until Pali 1 is fully i:LSiiilJiCICU.
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
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4. 3uLUri Nt vV- L1Ct Cd application,with any required
CquIrCd attachments for review..
An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: verne heatherly Date: Nov 20, 2022
Mailing Address: 41 fir crest pl Phone: 2064591179
Parcel Number: 42216 51 00073 Division-block-lot: 10 73
wireheather&
Type of Water System .,-nenraznnly Nov 20.2022 31D5n Reason for Application
Rl Puthlir/r nmm,inifi/Water System (7 nr more Ru�i!dinn pe (/)rmit Lt/ go33-00 R8�
connections) ❑ Division of land:
El Individual VVQlct JIJU{LC tVllc LU1ItIcL.LIVI lj, #of Parcels'? SI'L
0 Well ❑ Boundary line adjustment
u Springisuriace water
El (explain) ❑ Other(explain)
f.-1 Rcplcccmcnt or Remodel (please indicate name
if you have more than one residence connected of water system below if applicable—no
to this ,a,s !l ncr)r4 the P,,hlir'/r'nmmVrnit INator signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
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Name of Water System: LAKE CUSHMAN SYSTEM 5
Water Facility inventory(WFi)Number: 035290 (write-none"for two-party)
(_] I am the manager of this water system. The water system has been approved for' Ervices. There
are presently connection(s) in use.This will be the connection.
la I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection nn thic system(i.e.: recreational to fill!time) Plcaco indicate on the follo.ying line the natuire of
this change: recreational to full time
This IlJ TJatei system ii i5 able arid willing to provide water to this (these)connection(s)I(..)without CJ.Lt eui:;g the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager RANDY BRUFF Phone 360-877-2728
Signature of Water System Manager' • Date Nov 21, 2022
This form may be scanned and available for public view at www.co.mason.wa.us.
3:\Eli Fomis\Drinking Water RCN tied 4127;2021
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Individual Water Well
Individual Water ■rcf.
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) qpm qpd.
The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests ire noted on the water well report_ Results from these tests Will he accented. 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://clis.co.mason.wa.us/planninq 14_ 15 16_22_
Water use or limitation recorded N/A Yes
Well Drilled Date }
individual Spring/Surface Water
❑ WDOE 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
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Part 3: Mason County Community Services Evaluation (staff use only)
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Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
ater indefinitely in the future,or guarantee compliance with ail applicable WDOE water resource regulations.
If Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
nu.,....coy for Bui!ding Pormit arc octisf cd dditi,na!Growth U. ..ont. a. t , appiy. Chaptor
36.70A RCW.
Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
Reviewer's Signatures:
pn/� ��/�
fEnviron. Health: ��V�V ► � �b ' ' ' Date
This form may be scann and available for public view at www.co.mason.wa,us.
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. 2194642 MASON CO WA
• 03/08/2023 11 45 AM CERT
VERNE HEATHERLY #184900 Rec Fee: $204.50 Pages: 2
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Return To • REC�-I` rI �,
Fes. v s.. V n .i✓
Let' ) r (/ t ENVIRONMENTAL
p. B o 1622 HEALTH "� t J LvLJ
J &lQ g85,0" 615 W. Alder Street
Grantor(s): (1) (/eril ( , Hora ci- (2)
Grantee(s): (1) PUBLIC
Legal Description (1)
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 2 Z I - 5 / - 0 0 / 3
CERTIFICATE OF RESIDENTIAL USE: LIMITATION ON NUMBER OF BEDROOMS
I (We) the undersigned grantor(s), hereby place this notice on record that the above
described real estate situated in Mason County, State of Washington; is subject to the
following understandings and conditions:
1. The use of this parcel will be restricted to no more than Z bedrooms.
2. The on-site sewage system was designed for, and the building permit was issued on
the basis of no more than 2. bedrooms, and a maximum residential occupancy of
no more than Lt persons (two persons per bedroom).
3. Use of the other rooms as bedrooms, in excess of the number identified herein, could
result in hydraulic overload and premature failure of the on-site sewage system, and
could result in Mason County taking steps to cause vacation of the premise.
4. In the event of any future residential remodeling, expansion, or replacement that results
in additional bedrooms to the number specified herein, the property owner will obtain
the appropriate permits for expansion of the on-site sewage system.
Dated on this day of Victi,6,0 , 2001A .
Signature of Grantor(s):
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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 3`6- day of frl(,L ire..l� , 20. ,
VVv Nc. ( " personally appeared before me, who is known to be
signer of the above instrume9 , and acknowledged that he (she) (they) signed it.
GIVEN under my hand and official seal the day and year last above written.
\\.`" L ///, 46-411j
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oao��� �i'� Notary Publin and for the State of Washington,
No v'° '�cn= residing at St'lc(-4i11'1
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ry m A, .Nib'- Wiz= My commission expires: �(V.*.. 230
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