HomeMy WebLinkAboutWAT2024-00139 - WAT Application WAT -pp1,
MASON COUNTY
COMMUNITY DEVELOPMENT
rerml[ruslstarc Gents,BulWiry Manniry
415 N 61h Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 a Bellair: (360)275-4467 ext 400 6 Elma:(360)482-5269 ext 400
FAX(360)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/ Parcel Identification
Name on Applicant: Josh & Debra Heblich Date:
Mailing Address: PO Box 706 Belfair, WA 98528 Phone: 253-320-0053
Parcel Number: 32334-75-00131
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more 0 Building permit e;Lmoa4-06337
connections) ❑ Division of land:
O Individual water source(one connection), #of Parcels? SPL
I7 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 PublialCommunity 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(WF0 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.
J:\EH Fmms\DriNing Water Revised la52Dlg
Individual Water Well
r` Water well report(attached to application). Depth 'Z
Al Well capacity Test(attached to application) ZO gpm d 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.
�1 Satisfactory bacteriological test(attach to application). b/70D Zj
Water Resource Inventory Area (WRIA)
Development within which WRIA http,/Iqis.co.mason.wa.us/planninq 14_15416,r_��,,��22_
Water use or limitation recorded................................... N/A_Yesyc —lrsa1 sto
Well Drilled ............................................................... Date /0/zwigZ3
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
jd 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 urce regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter �tion of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements a y Qllppler
36.70A RCW. �//`�tj
G Unsatisfactory Determination: M APR O
Applicants water supply does not appear adequate to meet the needs of its rt 1� a for the Z14,4g
D fnOyhffNTAf yfA(rh
/d%./ � Reviewer's Signatures:
Environ. Health: Date Z
This form may be scanned and available for public view at www.co.etason.wa.us.
Page 2 of 2
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Paul ,WA
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Spectra Labs - Kitsap, LLC (Poulsbo)
J SPECTRA Laboratories-Kitsap 26276 Twelve Trees Ln NW Ste.C
...ws....=n•,I•K•.m.., Poulsbo,WA 98370
Phone: (360)779-5141
www.spmtm-lab.com
Spectra Labs - Kitsap,LLC (Poulsbo)received samples for Davis Drilling on Thursday,October 26,2023
at 11:50 am. Unless otherwise noted,all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
233582-01 Debra Heiblich Well Head 10/25/202315:00
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spema-lab.com.
9pR 4�
RFC 31p16
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This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in erroq please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
I013112023 Page I of I
2208490TMAS0N CO WA
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HP RT#195]01 Rec Fee' E303.50 Paaex. 1
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Retum to:
Dale Hart
1571 NE Tahuya Blacksmith RD.
Tahuya, WA 98588
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I(We),the undersigned gmntor(s),hereby place this notice on record that the following described real estate situated
in Mason County,State of Washington;to wit:
OR 3W 23N 34
Subdivision Division Lot Range Township Section
and having the Tax Panel Number of __ 75 _ 001
— __
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 Arm or WALL.
WRIA: 15 Maximum Annual Average Gallons Per Day; 950
Dated on this D4 day of 1" 04 0(1 70 DL�—.
Signature ofGrantor(s):<��
Printed name ofGrantor(s): vOSh �^ �`FC.�tf-�7 �b `�• b��'�
Grantee: Public
State of Washington )
County of Mason )
I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that on this
_day of 202r . .1ncl...� f T?e , Neb/i k persnnallyappmred
before an ,who is mown to be the signer of the above instnwent,and acknowledged that he(she)(they)signed it
Given,under my hand and official sml the day and year last above wr'tau.
,,,,gyp"`p•C\E
"'1��E ..... .. Notary Publi and fur the State of Washington,
at" •• 5073 � 'P ''.
Sm
liesiding at
• p10TARY Is My commission expires: 4
. OF WASH„a``.
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