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HomeMy WebLinkAboutWAT2023-00281 - WAT Application - 11/15/2023 WAT 2023 _ OD2& 415 N.6n Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:3W427-9670,Ext.400 Belfair 360-2754467,Ex1.400 emm.y vsnm,ymmmm..a.ueam<emm„mn n.,en Elmo:360482-5269,Ext.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: urll%a" oe'l/.rc Date: Mailing Address: 22/ V F ir every d4L Phone: .34 U- TOO—YOJr Parcel Number: ';X33?v .`{n- 00 Z 49 Type of Water System Reason for�Appplliicaation Public/Community Water System (2 or more Building permit gr rtibvr_j'O1_'L1oZ- 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 ff 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 CC,wg uorJ .9—PG'` W J-( , 5 yf/r.n Complete the section appropriate for the type of water connection being evaluated: L L_ Zn7?— boo 33 Public Water System Name of Water System: Rl i e.� L. J 1n ure 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 I connection(s) in use.This will be the .7- onnectlon. ❑ 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 stale 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. JAEH Forms\Dnnkin8 Water R.Ai 4/4/2019 Individual Water Well 'If-Waterwell report(attached to application). Depth f� ft. Jq�.Well capacity Test(attached to application) I!;� pm opd. / 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 stabilisation of draw-down and recovery data,must be performed by a licensed contractor. Satisfactory bactedotogical test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA htto://ais.m.mamn.wa.uslolannino 14_15 16_n22_ ,_ Water use or limitation recorded................................... WA Yes �^'1 Well Drilled............................................................... Date 1 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 Indefmftely in the future,or guarantee compliance with all applicable WDOE water resource regulations. Recommended appmval indicates requirements of Sanitary Code,Tille 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 mason(s). Reviewer's Signatures: - Environ. Health: Date l( s � - 5 This form may be scanned and available for public view at www.co.mason.wa.us. Peg 2aft WATER WELL REPORT grow uM+Lt w w.n.]"•.ry..e..,'a.r-rr CUKMNT cafuvud lg',n dn,.) NebLo,RIMIe%, W"sdso conmabn U*w Pmbp WOE M TLj No. BAC SDI t Da ixion O%OMAL OaTALLITION wmlU�.l4aAN0. Notkeofl.Y Nunbr I r.o•mmu,e . o�.y p ssw�n pY.4}r hoMIYO.Nm. Am Or. 1� j 0.vr nm.o. ❑]..ra ❑ well Some AdNe" 190NSULresralm Dr. I ,mp.nm o...•.r.r�uNo.rr , T.buY. Cuvq k.r lnndmN�1l4 Wd1L' VI s.ILLTw A m O p,.y R�IILIr�rrl I.rlra Lil.1 !. (44r HiMl NLOVYt6D) y�Q Om r>ors,RUCr,a.aDuu WlLonq LU Deg LU M' _ M 6 Oa lm 1��L.�� L r1iL UlY.YrY_• tl�ia� L._L LYYg De{ IMg L. 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Fee?TSM.50 Pages: 2 741 AM fAW& Lh 24 -roAli dJ PO ui7x Grantor(s): (1) �1' �/ Ar &:ez (2) Grantee(s): (1)PUBLIC Legal Description (1) 7 (19 r 2 u OC lyigyo. /ALP, (Abbreviated form:i.e.lot block,plat or section, township, range) Assessoes Tax Parcel: (1)L� .. o - o 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: ) S- Maximum Annual Average Gallons Per Day: 9�77 gallons Dated on this 9 day of //7 . 20Z L. Signature of Grantor(s): (1)", 4 (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 certify that on this 61 day of OLA-0b.C4- , 20 z3, 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 d y-a year a a wnn. r0puiulrrp�� N ry bli ' and the State of Washin ton, STA/"'0 residingat _ 2 e. ?.?F�'Soio .? h.oFQ ••:: My commission expires: S 10 Z7 mralfrI z O I/. ..ym..... ry�4ic 0rF VYA�+����p Page 2 of 2