HomeMy WebLinkAboutWAT2024-00055 - WAT Application - 1/29/2024 AiftMASON COUNTY WAT
COMMUNITY DEVELOPMENT
xrmsnannma« .Hiatt .Miming
415 N Be Street,Bldg 8,Shelton WA 98584.
Shelton:(360)427-9870 ext 400 O Beaalr(360)275.4467 ext 400 O Elma:(360)4625269 and 400
FAX(3W)427-7787
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/Parceltillentillication
j Name on Applicant: l 1111E Date: .t I -gel -202`4
Mailing Atltlress: S 0 �f1L11'/ln1_l�tc'_ Phone: 7y Ytelir-141 200 - 855 - 5✓'4�]
Parcel Number: I&nr�, -rX WA5 I a03l - IA - �10030
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more Building permit �LTILi 202S-F-0017. �j
connections) ❑ Division of land:
❑ Individual water source(one connection), it of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
1-3 Other(explain)
❑ Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below If applicable-no ..DO
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to this well, check the PublWCommunity,Water signature required) -,f�
System box. ,,n -1�.-
Part 2: Water Connection Information _(.�`�2
Complete the section appropriate for the type of water connection being evaluated: V"
Public Water System
Name of Water System:
Water Facility Inventory(WFI)Number. 1`16yI
twirls'none"for two-party)
I am the manager of this water system. The water system has been app vad for a 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�.r � Date 01/31/2024
This form may be scanned and available for public view at www.co.mason.wa.us.
1 TH forms)prinking Water Revisal Mnolg
Individual Water Well
Water well report(attached to application). Depth_ \ 1I ft.�j'Q(��]
Wall capacity Test(attached to application)�gpm ad.
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
toa licensed contractor.
tisfactory bacteriological test(attach to application).
Water Resource Inventory Area(WRIA)
Development within which WRIA htto://ois.m.mason.wa.us/olanninc 14kl1=16=220
Water use or limitation recorded................................... N/A F-I 5-1 [i Vest�/
f/1
Well Drilled............................................................... Date v7->
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 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:
Applicants water supply does not appear adequate to meet the needs of its Intended use for the following
resson(s).
1�r�a ,, ',,a Reviewer's Signatures: / i..,
Environ. Health: k I""y ' —' _ Data Zlu 1 I!�-A
CSD Director: Date 2ef2
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lbLO2023 -00aiD
Igyy2��_�g�1��[[[�-ryry._,412@ MASe■ON CO WA
Retum To ' I '__•� ■ Cr.l rr:n
e wrr4J t1AX FEB 2 3 2023
pry o YX '{Ya L� 5 W. Alder Street
ENVIRONMENAl
f HEALZ H
Grantor(s): (1) DAWO G K-TEt= (2)
Grantee(s): (1).PUBLIC
Legal Description(1) TR 3 OF GOVT LOT 1 8 TAX 753-A-1 LOT: B OF SP N1104 S47163
(Abbreviated loan:Is.lot blook,plat orseclion,township, range)
Assessor's Tax Parcel: (1)1 2 0 3 1 _ 1 2 _ 9 0 0 3 0
d 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
condigons set by Washington State Senate Bill 6091 and Mason County Code 6.68. These
restrictions and conditlons are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA:
Maximum Annual Average Gallons Per Day:q%50 gallons
j Dated on this day of 20 L-?
I({i Signature of G an p
I (1) (2)
State of Washington )
County of Mason )
i
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Printed From Mason County DMS
Printed from Mason County DMS
d
I,the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this 23 day o1 rC bfltotiRy , 20 25 ,
Dpvtd j}441Son personally appeared before me,who is known to be
signer of the above Instrument, and acknowledged that he(she)(they)signed R.
GIVEN under my hand and official seal the day and year last ab Mon.
S Notary Pa6 Note and 01 State of Washington,
0 State of washle{loo residing at W�" O-0 UV�/
ARLkNE M PAYSSE
MY ComMMSION EXPIRES My commission expires: j2w 2 /iDZ5
( 1=912025
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Printed From Mason County DMS
Printed from Mason County DMS