HomeMy WebLinkAboutWAT2023-00164 - WAT Application - 7/11/2023 MEN�P� MASON COUNTY WATa0pa-001 (ofl
COMMUNITY SERVICES
Bu iKn4 PMnYg EmYonmeMl H W rh�,mamiy 1MNM1
1 415 N 60 Street,Bldg 8,Shelton WA 98584, D C(`C I V E D
Shelton:(380)427-9670 ext 400 8 Belfair:(360)275-4467 ext 400 O Elma: (360)482-5
FAX(360)427-7787
Application for Determination of Water Adequacy JUL 1 1 2023
Instructions 615 W. Alder Street
1. Complete Part 1. No determination can be made unfit 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 Identi Ication
Name on Applican . I cL 6,,Date: o 4/to(a—d
Mailing Address: 140 x`l.t 41r12 l n_ta.a Phone: 12�'A 64t
r � �h 18"E5
Parcel Number: qa -43 h — cn .n.,yx,r
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 8—Building permit 6 walv5— 0078 8
connections) ❑ Division of land:
Individual water source(one connection), Is of Parcels? SPL
X Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
ff 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.
Part2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
❑ 1 am the manager of this water system. The water system has been approved for services.
There are presently connection(s)in use.This will be the 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(Le.: 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J TH Famu\Drinking Water Ra,e d 12�201 A
Individual Water Well
Water well report(attached to application). Depth 2Z I ft. > p�
Well capacity Test(attached to application)�gpm ' V V gptl.
/ The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests are noted on the water"it 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 WRlA htto:/lcis.co.mason.wa.us/planning t4015�160220
Water use or limitation recorded................................... N/AQ Yells\i
Well Drilled ............................................................... Date
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 600 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 6.66.040-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
reasons).
r�y� cReviewer's Signatures: l
Environ. Health: ate-")f "c^r \I� a,y , Date LO
r
CSD Director: Date 2 ofz
WATER WELL REPORT DEPARTMENT OF Nolue Oflnlenl Nr. WE46303
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p cers.t.n Sim Well Name(If more thereon,well):
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Si um Address PO Box 1790
-Licemeld..2874 Cut,Sued,Zip Shelton WA 98584
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ENVIRONMENTAL 2199352 MASON CO WA
HEALTH 0tH112023 02 05 PR WTCE
RRYMONO COLLRZO Ina0600 Rac Fu $201 50 Pspes: 2
Return To OL99bR3 �00 88
IX.Cnitm gECEIVED
511 a A.),Z 11&JC.17 w Lei JUL 11 2023
i 1.w .�A SR `;RSi
615 W. Alder Street
Grantor(s): (1) . (2)
Grantee(s): (1)PUBLIC r/tfS�LL / aL �
Legal Description (1) P L-. - to S�r71a3(Z-2
(Abbreviatedrorm:i.e.lot, block,plat orsection, township, range)
Assessor's Tax Parcel: (1)
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 and/or Water Resource
Inventory Area or WRIA.
WRIA:
Maximum Annual Average Gallons Per Day: �,750 gallons
Dated on this // day of TJ I
1 20a�.
Signature of Gr ntor(s):
(1) (2)
State of Washington )
County of Mason )
Page 1 of 2
I,the undersigned, Notary Public in and for the above named County and State, do hereby
rtify that on this II day of Sak- 2023, -
Md -u-..q LpC nll gaq rsonally appeared before me,who is known to be
signer of the above•instrument, and acknowledged that he(she) (they)signed B.
GIVEN under my hand and official seal the day and year last above written.
oE M K•P „ Notary Public in and for the State of Washington,
pp�� •saioh p•..�! ' ' ff
`.44 `TAI,Vq s `= residing attA
21009497 w - Mycommission expires: �I I�6 �UJw
' Tp PUBLIC _
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Page 2 of 2