HomeMy WebLinkAboutWAT2023-00228 - WAT Application - 8/29/2023 WAT
MASON COUNTY Shelto WA 858
COMMUNITY SERVICES She= 360-427-%70,Ext 400
Belfair..360-2754467,Ext 400
mod,Phwlnye�can.n.,yxhm, EIma 360482-5269,EA 4W
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: sl.wn maeon4 Date: e 1 ze 12023
Mailing Address: 44o a B.r.on.1W rid R4.s,sn.imn,ww ease+ Phone: 601,710.4573
Parcel Number: nol411-worn
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more la Building permit $LD301$-010A-7
connections) ❑ Division of land:
m Individual water source(one connection), #of Parcels? SPL
(0 Well ❑ Boundary line adjustment
❑ Spnnglsurface 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 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.
❑ 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 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.
III] Water well report(attached to application). Depth
Id Well capacity Test(attached to application) IS gpm 7 U U 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 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-clown 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 htto://gis.co.mason.wa.us/olannina 14)(,15_16_22_
Water use or limitation recorded................................... WA_Yes
Well Drilled ......................................................._...... Date als lzaa
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
ater 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:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: -YV'\ Date tb
This form may be scanned and available for public view at www.coinissain.m.us inissain.m.us
WATER WELL REPORT E�OLOCI, N.KI nfmrmr No.WE@M
/M'Mu an:>r..•r...o. 1'III4-EmIoB)KeII IOTey R'o.BpO1BE
.. Sile Nell VamcrilrmmrM1an me velll'.
Rormeruiw q Unyiwlrurelmrw.v Wmn RiOlPmnitCrnrfinrc4o.
Pnpwe u: _ L1M—W :]MwerNl pyn,n( Vame Elm OummE
G In Nell :](TJer_
Wdl Smn nJNtia 1 W E Harmtire Islantl RE 5
., annne Imry+rw
•Mew n'e0 Cllrcnrmm ]pi,m CA,,J id nl CrrY EM1ellm _ Cuunn'Mdson ,_-___
7 delnnnfl pPy C Ao- C V
WRo0.ouy iv Pavel\o.220A N 119ID _
pmewLe:Uururnr„lArt:rg6 .m IW P. Nesaaanurtte
wprn nrmrrpRrJw<n 1as_R ppm.W Rn rEia war^ �ve. a�..
�u.ee..Ra+W: w.n Br.+Nhv waa lnT+ari.mclia'�
faae 1� Ta lgkk,uu Srcsl NIWM ArtJ
� ] 6 van a_ 135 1 i C Lo[alim lam innrumm+m qye A'. ❑KM1V.N vO EWM
NE f. .uflhe NE 'a:saclim Nq Township XM Rm¢ Tv
'7 O _r . _ InilWvl L+aryrle 1?.12M,47] 5
n hrYnYa: OYn O Vv ]m,We l ampk:-I2012N -122BRIM
n iyyevfpFvarnowt F 31
U.Upa4mrie SisofRrfeuvm_rn.M_in "Ws lq/CoaurvnNaor Rnvemh+W Fa a[eu
PSRvne.lfum_Rm_AhM puntl+md ..M1urvrer.ave vl nu ertntlaN
ireem: }vn ]Ne ;R.PaelnO GpM1 pY q wrpnnnrcun arYnrmm�rn 6ree,M1Rmyeo(
Ms6emm'a Nam Mm nn^Mmmal Fm
Tpe Mrbea MNN\b_ To
0.aurne+ +e l$ rn. lX a.-L. P T a0il 9_ 2
nr.::.u._M1. same_ m.Mm_nm n Brown asW6 mal same cmv 2 im
4WFlgn ryeY:�Vn -No 9veullxt mmel_m BrWn eW089r 1waler[earirq 10B IQ
M111,16 praetl(rvm_R m_
Sarluefal: BYn Tn Nuh,,tR, q,
til MMIe
r.rrm.waw.rar ovn ow
rns Wpm vfmw _
n.p:MmoMmrtian.m noM.. Tra-are
xr t rwyrmatea�prn:tb R OuiRmd mr m..12 pm
nerltaAr:leNw(weelnmm�an,..rrw rea knl R
srra.rr,r:m•lealn,irry_ n ..R..w mrme —
9] velleainy IMu
wrtrnM1 Me_
Ka Tao:rrr�•p�H•v Mr Nrromrea^�.. — —� M.wmm^ —
XJnvSrunafln_M
v afla_M.
YeW_®mwN_RJnvJ un aPn_M.
-nm whn WmD a rwrcJaR-raaurinel wvmad fiemweB
Tun 4 Nar l T.— Nomleml Trm: wa 4rt
IMuorNmp e� —
m8 ®mwYrB RLnwMnaRvt M.�
_epmwMnamwu_P.b_M. � IY:. —
.aryaun Mr_yqn
myu+wnalwm_"v uuy.i.m.a.' noro Eun Wlc W1122 C.,l,tM Dot RW2
"MU CONSTRUCCIOR CERT6ICATION; 1 mnaw.url nN:wettap rtpmebilYY fu vwwnim olrl:ia xdl.and ivaamplieoc<wiRall Warhglm WI
<onwnrcnm elaMnde.Wlmax u+W aM We infamelX:n rmmW�xpe Inr w�bm Wwn'IMye aM Mlief.
�Onyn Otnvua':'PE-Pmr VameEmgy Davls OrNm Cm nr Oms DIM,
silperrrt Gi ICY AdJa M ME Dario Farm RE
U.N.31V Cilr.s 2u Bgtlalr,WA MK8
M TRAINEE:Swnacr'a liawue Vo. C_.s
Epau sipremn Reaiemlwn W,WymllloOR Ipre AVO 2W2
E(N 0.1301Rm'MYI91 If-ueArhi•dm ..I man vlu.mnrWmut pl— .1111,RP R..uun'n Rr,gnun ur iHe10z6B:,
Prm Ih I'-,,4n.mnmil 111 ,,,1l u.,r Rdyr S'rn.v. Am—..u+ry'a'a h dl.N:l,I mll 9)LR31.6ll1,
I
11B65ENMM11 �1
De ''. SPECTRA Labowtorics - Kilmlp
PM QWrEi WA , ...NArtrapnlee�s mCnn
9B]96
COLIFORM BACTERIA ANALYSIS FORM
Dote sanple Colrx+e0„�. To.samPW county
coum tl
TypeWWrtrsyeMrn lWiedamybm�)
❑Gmup A ❑Gmup B fj ONer.Al [�
GmupAmWGmupBSOW.—P.We 9om Wa FWAIWW 1*'enWD'(WFI}
Im
so.Nerre'.
Lin dtae.
Cooled Pembn:
Je Pbbne:(
E.W.
'ienE n W b b(PM U mm,emeu eM Wp roes n smeQ
AWLERFORMATION
Samge mllxbE M lneme):
spxWclomlm MroeanpWMWCWd: Spedalimwctlou or mmeMs:
T9ge18mpY agemgyeolwipbfian least Nmuyis5eWA9
1.❑RRulim DWtMWtbn Sample(AIP) 1.❑ Repeat Gem&(AR)
Cw.w:Yes_No_ 9mm 5enib arrmm nbr unzi.m -)
Umalsfado routimbbnumber.
CNOWWReuUl:ToW Free_
3.DreuM Weler RW�eSwm� 8unpk DnealeHtlory lWGle mlbcl Eebx
LJ�LJ J I-
CNbr mWd:Yeo_N.
❑Tfig,• (AP) Cxbine RaNJmIJT l Fna_
4, SWgosorMRen Source Wabr SmpM(Enum tm) _ I
❑E.o ❑Feral Fra�m ves_xo_
s. Smple tdkmElm lmormmwn Dory:
LPB USE ONLY DRWKING WATER Rl XTS LABUSEON.Y
❑umawlaororyTMal wlWm Preeem ape bhelay
❑EroFpmseM ❑EcolaWM
BeWarielMm9y Resulh:TalW CallWm moo WWml. Fmn new1WM
Feral CgllRm M 1100m1. HPC nM.
Reol .MSemp4R,WWd: ❑TNTC ❑smpww*
❑ Sampb VONme ❑OamegeC Cwlemu ❑
Ub Releleme N
t Imo
Peoxpremp C'. woe Catle' MUM ar SM9MD
Oen Repwltlb Ubl O*
OON
3� 10 py1o2,
axnnp..rxr Nw.J6. DIVMrvYT
M�Yu��p`rw�Y��+M+{YYUM
IMMUNE
2201456 MASON CO WA
Return TO 0812912023 01 52 PM N07CE
^, \ 00MOND #190289 Rec Fee'. $204 50 Pages 2
INb t dS` IIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIII IIIIIIIIIIIIIIII IIIII IIIIIIIIIII II IN Grantor(s):(1) ��"�� 1Y \�(�ID�,�r. (2)
Grantee(s):(1) PUBLIC
Legal Description (1) 1 115 nt i rLi v
(Abbreviated form:i.e.lot block platorsecbon, township, range)
Assessor's Tax Parcel: (1) c�. o3Q
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: I
Maximum Annual Average Gallons Per Day: I �D gallons
Dated on this day of kuu 20�-�
Signature of Grantor(s):(1)— — s d/
• (2)
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
ce/rti`fy that on thisrday of 20L_,
S1'E�/!✓1 r� ✓nrsn ersonally 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.
.ae VV16- i,•�Mc�/s�
Public in and for the State of Washington,
V1E7 q residing at ,S r
sg PZOja,�ms My commission expires: x0�4
y�a07AR �• c 1
ANT;i6pUBl1G\��••0
11%. `
WAS
Page 2 of 2