The URL can be used to link to this page

Home My WebLink AboutWAT2023-00339 - WAT Application - 11/27/2023 WAT 0a�- 60339 MASON COUNTY COMMUNITY DEVELOPMENT FamR Itl Me Ue ..Building Planning �F 415 N 6n Street, Bldg 8,Shelton WA 98584, / Shelton:(360)427-9670 ext 400 4 Belfair: (360)275-4467 ext 400 6 Elma:(360)4825269 ext 400 / FAX(360)427-7787 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 Name on Applicant:L_ CA. Im� _Date: 1 1- 2-1- 25 Mailing Address: E 1fC*- 9CL Phone: OS3- 310-8SsS Parcel Number: 12-1A7- -842-5636b 61_AU-4/ WA gW69 Type of Water System Reason for Application 10"Public/Community Water System (2 or more Building permit 31d26Z4- b rv12.9 connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ 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: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: L Public Water System Name of Water System: TYGcict . 241 6U Water Facility Inventory(WFI)Number: nor)E (write"none"for two-party) Id' l am the manager of this water system.The water system has been appr ved for Z services. // There are presently I connection(s)in use. This will be the_pdconnection. ❑ 1 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 at by tale and local regulation. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J:EHFame\Drinking Wacr Rmv 1/250019 Individual Water Well Water well report(attached to application). Depth ' ` ft. r � WA31- Well capacity Test(attached to application) LOZ3-OC76gpro 7� 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 144�15[=11=22= Water use or limitation recorded................................... N/A-EZI_2 Yes1//�� Well Drilled ............................................................... Date _t f/ `U Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 1 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: Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s). n�R(eyv�iiewees Signatures: Environ. Health: �I�l /'`^' ' N' Date CSD Director: Date 2 or2 WATER WELL REPORT CURMNT a.y.aa r.n-ww.Y wa.Y.p-W Mrb.fMiwlr� �� C.YlrvetlnlDaY4Yea(1 Ir e4da) lalrr Brl..MV IDTyaa.l0?7 c ..U.Cdoa pyraldtrreilFw aOarammW"0R101NALIN rAUAT/ON rnyrDOrrrNr Yarn.Na 3 Natica Ghni NmaW rrprou® .D..ra OI...r rra+W wYY AAa� OrnlrwL Fa. O O,.qa O ab C1F Ulaaa.Yw C p...... mawras� o..r.r.wrW�.r..d— p Ialw�wul�In Srl ra}!_aL swr❑ pu �' .a ❑ .._lra. IIM.I:O u` a. ❑�OpN�m.vrrwY�ra Nbl .lf a r M 6 runloxaaruu■rrw .f—' orrin•Stia 13127325M OIIaW�� P�w�lw�maM La l�"`� oaDnae..r b arar, r. O w O c.w. I.r.• F Y .r.ra r.wb.aa..warrY k" lww.r�r=a.�La rr a. anrnd+ in Ow ■.b r.rr.rr_ nallrna�L.�6w■r. Ow urrA ^JIrar .+rra.ra - " Ova w.rd rrara G. r1lY6KM Ial�Mr..\.lwr a.�Y!_L lrar�abb.wrr or � rvn.rrr $ rma,ala oww..aar.r`.xni...rr...r.ew r..�rrn Ora ■w rrabw� ram•—�.�.r a r.aw Mrr aer...JLwr.r2Lnsaa..rl.. lA! et.._ru.a.rrrr_nr_r. wera._ar.M u.r,,..rr_v..r.nrrwrn Ov. .r 1r pNMiS Wiylr pO aAn. N.I LUMI.ILTIpM OpaOICAiIaY: IamuRtl r.dbrrq waa+llla'rmwdmaf W rl.r bm.rllr.e�10�w.Yas rl mMseb.11ar Weld.velrblaB.mlamiWmr�Oren6sbn0'6.abwMMa.r Ybr. pnh TY.b )Im Deb - PYeafw®' Dwu OrY11[ A•Ym S19 NLDwb► AG 04, Ltriltr.r4rlJobraallAt l.Ihlr WA MS1t F1LAQ✓1a p..f 4 . Ala C.ou.rdl d palnf.! agWrba Na DAV®lllgA W. Fi MU �Jlansna l.F�ra.aWrem aaoW b`rnrirrt..r. w �4erm.masau 9ason Panted from Mason County Bt" TnrUww secc .'I SPECTRA L yortmrirs Kiuup RW.hw WA rr¢sm COLWORM BACTERIA ANALYSIS FORM a.Ybr.bCtlrbp Tm.6ri�. Corny 4 IaLfl if cawe e. r a w I /7.41ah TIPdIWIwp�".w-4—E ) M"A W ftW9SWb-P,wiYM W.YI FUNN NW A" W/R ar..Nrr 3,6t F. /yrrl4..r ce..�a Grbdl..a: '/ wr 1 pNPb,t f1Rm.j j • I bP! Fw Rlen. arrelrrw.rr.rw.t..rrrwwr.wrwr SMIPLESIFORIA y,sbraeseOMkuet 8n�brl..nn...W..rtrea. 3C.a.lY.Ttlb.voamri.. kAl , ...a8M1�4M moml I.❑s.,Wr owrimn s,wM WPC zps.yrsw..IUR a .r v. ❑ wc] lu.�senmen.nrnnrwa rrq aeN,enmrrau_F.. u.rdlmy mr.W.,nAer e � � � llstllYtlory,ouMeoYetlu� 13T,4p'.I IA VI CIbwW!'.vr_No_ 18uAW.aWI MrSourt.WWrBwpYlTnurMon) p ' ❑ E.cW ❑F" __ 5. S.n�V.WlalolbhM.An Miy 4 ONLY c DRW=WAM 1. ll ❑UW.Iil.cbryioWCrbm R..I.n! ' .-. ❑EWl .l ❑Ewr.MN aM1a..WTA..lb:ia.IUr,nnW10M.Em1�rn00,i f..l aaf.L—__dY1WM NC__¢Jlr. awWo ft.PrW.Aw : ❑WC ❑su.Y...W ❑stwi.WAuw ❑D..WC.rFr ❑ 2oD "°" •'3 o flZ NrW Tr.0 Wu.O.c Ld.t,9.1ffi U+ wa. .....r�.rr.p..s..�ri.. ...ryYwsT.YF..I�YI. .plr•tMwIY,.A Printed From Mason County DMS - Prinbsd from Mason County OMS 2204903 MASON CO WA 11/2112023 03 05 PM NOTCE C ESTRROFI INC R,92.96 R.. Fee $204 50 P.— 2 Return To IIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIII III IIIII IIIIIIIIIIIII Grantor(s): (1) G �'�Q�—ISnca2b1&}(2 ' Grantee(s): (1) PUBLIC Legal Description(1) L&+ VJ o�U-S= ID•ya ,4F I i8�3U (Abbmviatedfam:i.e.4 block Plat orsecgon, township, range) Assessor's Tax Parcel: (1)_J 50�, Tzl, W TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA) I (We), the undersigned grantor(s), hereby place this notice on record that the described real estate situated in Mason County, State of Washington is subject to water use restrictions and conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These restrictions and conditions are based on location of property andlor Water Resource Inventory Area or WRIA. WRIA: I`7 Maximum Annual A_verage Gallons Per Day: gallons Dated on this�-1$'t�` day of No V r .20_2:5 Signature of Grantor _ (1) (2) State of Washington ) County of Mason C' ) pa i Page 1 of 2 UeIIG � '1r I,the undersigned, a Nobiry Public in and for the above named County and State,do hereby rrtify that on this ay of f kwem)w✓ , 2013 , Qr lilt t,d....lrn personalty appeared before me,who is known to be signer of the above instrument, and acknowledged that he(she) (they) signed it. GIVEN under my hand and official seal the day and year last above written. . ........ .. ��. ,, .sN�14p� Notary Public in and for the State of Washington, residing at Ih.Son r6 ±:j vi it V • = My commission expires: It - 1-2 1 Z 6 PUBIIG I IOrrrOgq�T"````� Page 2 of 2