HomeMy WebLinkAboutWAT2023-00268 - WAT Application - 10/2/2023 WAT 201�- Wio
MASON COUNTY
COMMUNITY DEVELOPMENT
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415 N 6-Street.Bldg 8, Shelton WA 985B4,
Shelton: (360)427-9670 ext 400 o Belfair: (360)275-4467 ext 400 9 Elma: (360)482-5269 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
Nameon Applicant: 6ARBARASwIFr&DONALD EWINO Date: 1002r2m
Mailing Address: 202 NW43RD ST.SEATTLE.WA98107 Phone: 206-498d818
Parcel Number: 320245000014
Type of Water System Reason for Application
0 PubliclCommunity,Water System (2 or more 0 Building permit '-E"&2-3 -bl I
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. C)CID�l
Part 2: Water Connection Informationrv�f�
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: 460 WATER(TWO-PARTY WATER SYSTEM)
Water Facility Inventory(WFI) Number: NONE
(write"none"for two-party)
O I am the manager of this water system. The water system has been approved for 2 services.
There are presently 1 connection(s) in use.This will be the 2ND connection.
❑ 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 lime). 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 li t by state and local regulation.
Signature of Water System Manage Date 10/2/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
ITH Fmm DnnlaBWeyer Revix IMM18
Individual Water Well
Water well report(attached to application). Depth _tt.
Well capacity Test(attached to application)�gpm pd.
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[y,T5=16I=220
Water use or limitation recorded....._............................ N/AQ Yes
Well Drilled .._................_.......... .............................. Date 3 L) /
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.fia.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
C Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
y,,�O1M ,n ,Reviewer's Signatures:
Environ. Health:\Q V -- i "` ' Vc 6m Date
CSD Director:
Date 242
5 Please prm,sign and return to the Department of Etmbgy
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DOryN�PLD EppWING #1191365 Repp'c'II Fee:nn$20I4I .50 Pages: 2
Return To
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Grantor(s): (1)'tXl,(LAJ(V A J7-1 (2)
Grantee(s): (1)PUBLIC p
Legal Description (1),iJALn Yee-heS and (•dtmffz.d;>-Pr 1.1 of BW 01-I I
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 1&-z—2.2'4-,Z-&--DQ Q J——4
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 6.66. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: (�
Maximum Annual Average Gallons Per Day: 41Z gallons
Dated on this O Z day of 0c "Q be r 20 23 .
Signs Grantor(s):
(i) + (2)
State of Washington )
County of Mason ) `pay"p0p"j 2,,
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''nn WAS%
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this 62 day of (1(':1'6 txr , 20_a,
170y1l1I d A `r•WIV1A - personally 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.
`p"" uM a ry�p .¢i�{'y� I IAA , r n
\J '. i.. G9�'�. Notary Public in and for the State of ashin on,
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,`Q,�oFop-oa-2d��q^..yam residing atA&4b&r1V hrl}ly1
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My commission expires: Oln /0V 12021a
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