HomeMy WebLinkAboutWAT2023-00287 - WAT Application - 10/12/2023 WAT 2AZ3 - ooZS-7
415 N.6°Sheet
MASON COUNTY Sladwn,WA 98584
COMMUNITY SERVICES Shelwn:360-427-9670,Ext.400
Belfair 360-275-4467,Ext.400
Elm.:360482-5269,Ext 400
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 I
Name on Applicant: E1AKA �ttI'I Date: (OtrL 1Z-3
Mailing Address: ZzuSC.wu�I-+�l Sp9S � �hone: Zs3-- �I�—�`93$
Parcel Number: �LcVNI 'QLti.44./M//I r8Y66
_ Z-�6 coS'oo
Type of Wat r System Reason for Application
I(- Public/Community Water System(2 or more Building permit
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 Public/Community Water signature required)
System box. t�
Part 2: Water Connection Information -1.,v o
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 (is.: 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason,wa.us.
J:\EH Formal Drinki,Warcr Revi.d 4/27/202t
Individual Water Well
Water well report(attached to application). Depth I� ft.
{p,
of Well capacity Test(attached to application) I t� qpm :� 500 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 hrp://gis.co.mason.wa.us/planning 14_154/66_22_
Water use or limitation recorded................................... WA_yes ``X N�"1
C
Well Drilled ............................................................... Date 17 [ -
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 Detennlnat'on
:
/ \ This determination does not address adequacy of me distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
ecommanded approval indicates requirements of Sanitary Code,Title 6,Chapter 8.88.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicant's water supply tices not appear adequate to meet the needs of its intended use for the following
reawn(s).
Reviewer's Signatures:
Environ. Health:
Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 or2
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Printed From Mason County DMS -A3
Printed from Mason County DIMS
2203805 MASON CO WA
10/Y0l]0l2 01:17 PM NOTOE
l�dan To
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c� RY 80SLFv
Z?05CR` -STAL5PRINGS 2A. W, IJ
ubiwa5IT-1 PLAee ulA %4e- 2 ?z5� OCT 26 711
BY:------- ----- --
0�
T?A?0?3
RECEIVED
Grarnor(s): (t) BoSL-tf4, (2) CA/ZO — A 605 Le-y
Grantee(s): (1) PUBLIC /
Legal Description (1) -FR q- �TZ)Z� F 5LI12✓CY 2/0/4-/ PENDifV('rJPCt
(Abbrevia tetl fuirn J s/e.ax,��b ac rf,nf 9Q" fownship, range)
: �w
Assessor's Tax Parcel: (1)_I�_ - L_-�.Q_&LL�.
S'o2-raz- R3 3 Z a p ? - 7 6 - 00 Sa 0
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA)
1 (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 'T
i
Maximum Annual Average Gallons Per Day: gallons
gallons
Dated on this�day of(J`1 ,K.rlo� , 20
Signatur f Grantor(s): �'"`'"�
(11 . (2) �
State of Washington )
County of%seen'n
Page 1 of 2
I,the undersigned, a Notary Pudic in and for the above named County and State, do hereby
certify that on this L day of QCY4xv , 20 ';k,3 .
'9--a!V f -&2&-Lt4 Personally appeared before me, who is known to be
signer of the above instrument, an acknowledged that he (she) (they)signed it.
GIVEN under my hand and official seal the day and year last above written.
MEGAN SCMLAUDRAFF �`A� ��C —
NOTARY PUSLIUt1033796 / No i for 01e State of WashmggI,n,
STATE OF WASHINGTON residing at PflGv�
COMMISSION EXPIRES
OCTOBER 4, 2026 My commission expires: O S
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