HomeMy WebLinkAboutWAT2023-00176 - WAT Application - 7/20/2023 WAT2 23
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415 N.b StreetMASON COUNTY Shelta WA 98584
COMMUNITY SERVICES Sheltnn:360427-9670,Ext.400
'\ Belfkir:360-2754467,Ext.400
emery emu,iry,e�.;,o�m.,,mxdiht<�.,..nrcitwxn Elms 360-482-5269,Ext 400
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Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully comoleted.
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: Applicantl Parcel Identification
Name on Applicant://m� 0 u.e.. hlrlDate-
Mailing 7-2o-Z3
Address: gLA6 .U14 a! �P��i1. nu) Phone: lrnOplP�, INV1P/A!t//�JUIJiC.�Y✓1
Parcel Number. 16 t1 VL11✓A'&'L- bN 96f67
1� 5-zl - oalo
A/ Type of Water System Reason for Application _
Jd Public/Communiry Water System(2 or more ❑ Building permit 1612023
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 PubliclCommunity Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
- /t Public Water Syst_emL - [, ! 1
Name of Water System: (-ht)r&h n &,rL--- WLIT yL.NJl.1Yl-em
Water Facility Inventory(WFI)Number: hon15 (write"none'for two-party)
XI am the manager of this water system.The water system has bed approved for services.There
are presently I 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.
11
Print Name of Water System Manager 0IZV'- ?hInnLN Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
]1EFi Fa®e\Orio6'vg Waror Aeviud4/Z]2021
WATER WELL REPORT ` Nora of lnmi Nt WE42W
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anmmb plover.eom_hm_M1 Wet9rave 260 268
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Green sills 388 400
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SAMPLE INFORMATION
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LABUSEONLY DRINKING WATER RESULTS LAB USE ONLY
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2199788 MASON CO WA
C]/]0/2C23 02 51 PM NOTCE
"OR:E ' P,8396c Rec Fee $2N 50 �a 2
Retum To �� ��� ���� �� '.�.��� I��! e�
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Grantor(5) (,) YYlnnio� E'11nY12it . ( )
Grantee(s): (1) PUBLIC,/
Legal Description (1) I YL I(j-B of &L A £ n 7z i�- Ion 61 L of
(Abbreviated form:i.e.lot, block,plat or section,township, range)
Assessor's Tax Parcel
So5-723-Al
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 6
Maximum Annual Average Gallons Per Day: ` gallons
Dated on this day of ' 1 u 20ZJ.
Signature of Grantee(s): r
(1 7 (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 ,A day of Tkkk20-a&,
n Pstru ersonally appeared before me,who is known to be
ign ser of the above inm t, and acknowledged that he(she)(they) signed it.
GIVEN under my hand and official seal the day and ear last above written.
,>+ `! BRUT".,,,.
TARY "�`G ': o ryPlic in IId for the ASAtate of Washington,
209271 i = rsidin at �'IP.�MYI IAJN ri�RN
PUBLIC M mmission expires: 07-17 �f'L7
'c„mil OF WASN�aC°'
Page 2 of 2