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Home My WebLink AboutWAT2022-00266 - WAT Application - 9/19/2022 (2) WAT 102-2— - 6O.�Uta 415 N.6-Sucn MASON COUNTY Shcbun.WA 985M COMMUNITY SERVICES shOwn:3MA27-9670.EML41x1 a IfWr.360-275-4467.INr,4M mug.rb.,:acurum.,m x.ancou..�vx.,b. Elmer 361W82-5269.Ec 4M 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 t Part 1: Applicantl Parcel Identification p Name on Applicant:pr5RWALP Astr wwq d Date: Mailing Address: �(.Q . ,. 'S� f101 G-Wa Phone: V46- 7_7-5--52A11- i}} Parcel Number' 22114- Z7i— S[]U f ri S� 7 Type of Water System Reason for Application ❑ Public/Community Water System(2 or more Building permit connections) ❑ Division of land:I'IEI.s-PIIA?oZ�F-Dyr? f!{ -0 Individual water source(one connection), rf of Parcels? . SPL p=. Well ❑ Boundaryadjustment >- O Spring/surfacewater line ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name j Jr you have more than one residence connected of ureter system below if applicable-no to this well, check the Public/Community Water signature required) System box. I Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System I Name of Water System. Water Facility Inventory(WFI)Number (write'none"for two-parry) ❑ 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(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 aranned and available for public view at wivaLcip.malso wa.ua. Prigg d Ero,a�►l,�Mason County DMS sr,iwm4rzolx Pn'rlted fmm Meson County DMS Individual Water Well .Pt Water well report(attached to application). Depth R Well capacity Test(attached to application) Z.J apm 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 stabilization of draw-down and recovery data, must be performed by a licensed contractor. m Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA htto:l/ais.m.mason.wa.uslolanninp 14115_16_22_ Water use or limitation recorded................................... WA_Yes/" Well Drilled.............................._...__........................ Date Z- Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ,> ❑ I 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 B.ee 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 meal Me needs of its intended use for the following reason(s). fReviewer's Signatures: Environ. 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Wre &Val .any,e.._wrc TapYunoM1v_•F we,Muretl olWYwW1 DYe MNe ywn pey yLyll CmnIRrW 0.n L21/21 WLLL CONSFNDCTION CVWHICATHW: Imr}maM utlla ecepl repvaibilM lLrmnLrvaian or*mv 1,uW iu cmndimm wi0l dl wWWn twll RwwnxLm auMWdv Melmiele uni�W/llm�i�nfanlWim rtpwld0.bure ue Nnlo mY k km Weal U10 91 DN ws 0T0 m-Pml9ibll0oprWMllNr DIftc0wpny Armrlemftylnc. Sw Um Atlrkwa PO Rm 1)W I WNo,2p63 CtiW.Smm.2m Shim.WAORSG IF TRAOIPE:SpT..I..' No CoarnawY Sp -,Sienww R,W,Miw NO MCM01008N1 plan a 21 ", ELY 05DI�30(Rer OWM) I/Avmvdlku r4'rtl0w rxmW[�nnl.prmre mflOvW rRenwrn Vrymmar JOML)�RS)2. Printed From` 9*sZ""�m`C6d' EMSmr'. Prim[from Meson County DMS - ' -A/ArER a MANAGEMENT ANN, LABORATORIES,,,. C ° T•°°m• WA9e10f RECEIVED 4%w COLIFORM BACTERIA ANALYSIS FORM De43ample Cplleded Time SemOs County MAR 22 2024 W. , �X m�M„n p �� 615 W. Alder Street Typedwamr Sye m(awo"nMwl El Gm A 0G"8 ❑Omx__ Omp A sod Gmup 8 Spa4 Pmylda Bmo Wb FUN"h"Wy(WN�me ENVIRONMENTAL S1 _ _ Sye Na : 0 "' HEALTH Gonmq PwmnAr"I 'rilli Im D"M.:860 )4' 6-3395 Cal Pnme:1 ) E.W; Ew;Plpns:( ) Arcadia 7Yecadia Drilling, Inc ' PO Box 1790 Shelton, 1A _ 98584- SAMPLEINFONMATION Semple oNbdad by(nam): (y� SpetiRCb�wAeip earmm ,ll Spiw inabuctlwu ormmnent. �f 0 m`.1/v_ �GGJ TY1)aol8u i'(eeledanlymmryped. olPlpM1wn typosi Slm4R5babn) _- 1.❑Rouem 04b0ut Sample(AP1 2.❑ Repeal Sample(A/M Chlo,.w Yes No (sum auhbu Fy..W aovt muene( Chbdm R"Ul:Tabtl_,Fee__ Umebdatlwy moose lm rcumben 3.Ground Wa Ru4 Saum S."W -- ._._ __ _.___ Unmbstadwy mdme COWS de0e: CAbdmW:Ya No_ ❑Trv, .W(AP) ChWos RW":Tb4L_Fm_ ❑Assea t (AP) 4. Sur4w w OVA Rev Soum We4r&mp4(Fnufl e ) ❑E wN ❑Fe®1 Fp va.__m___ S pe Ctl W eU M Ir�lwmFtlen ONy: UBE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Umalbhotaq Tow CON=Present and ❑Emd pmswt ❑E.00y abmnt Saolmlel Mnalty ResuecioW Collbm� nlgd. EmY____JJ00w. Feral Colftm nl%ma, RPC nrtl. R9pSxmmhlSwP1s RagAW: ❑TNTC ❑Samp4 bo ow ❑ Sank ❑De..w eardwN, ❑ r-r � tab PeNram PAW WmpI TMm C: a McTOE �Q RepadMmpOX lab U-ftA004R DONttl4MpY ✓ 089 Z8 / i�i. ran.. r.w+�•�.-rr,.w:»ou� u ' �ww.oum•o,ww.....m.wuwwa 2186397 MASON CO WA c. Return (o �j .moo['=aid p:4 ?a,saa Pa...rygyxa 1 Grantor(s):(1,YZ,4 P Y,ty L r ) Grantee(a): (1) PUBLIC s(4-rZI LZ. Legal Description(1) T2� of SLYUs�J VO) 3 t"r4aa ym nE6WnO (Abbreviated loon:t.e. lot, block,plat or section, lownslsp,range) Assessoes Tax Parcel: (1) oZ r. I I 'I - a 3 - yr 6 U I 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, Stale of Washington is subject to water use restrictions and F conditions set by Washington State Senate Bill W91 and Meson County Code 6.68. These restrictions and conditions are based on location of property and/or Water Resource Inventory Area or WRIA. 1. WRIA: Maximum Annual Average Gallons Per Day: Q50 gallons Dated on this�_day of 201V1 Sgnatu rantor(s 4 (1) State of Washington ) i9 County of Mason ) 3 Page 1 of 2 Printed From Mason County DMS Printed from Meson County DMS I,the undersigned, a f�tary Pub[ In and( r the above named County and Stale,do hereby certify that on this day of 20 ?Z , Don ROC— personally appeared before me, who is known to be signer of the above instrument, and acknowledged that he(she)(they)signed it. GIVEN under m hen d i a day and year last above written. Notary Pe , ' � , Shte of Wu► � ie�toa A'`x �WI/.wn ARIANR M PAYSS6 Notary Public in and lor Me State of Washington, My COMMISSION P,7�IRPS 17129;21125 residing at_&Wpa„ CO_ ---� My commission expires: Page 2of2 Printed From Mason County DMS Printed from Meson County DMS