HomeMy WebLinkAboutWAT2023-00354 - WAT Application - 12/11/2023 WAT 2Z"* -
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J MASON COUNTY 8hdW,,WA98584
COMMUNITY SERVICES Sin 360-417A670,Ex 400
Belfair.360-275-0467,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 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 aooroved building site plan must accompany thisapplication.
Part 1: Applicant/Parcel Ida tification ^ /
Name on Applicant Date:
Mailing Address: m / l✓ �) Phonee�:11 ��L:?bQ • N.;l(0 ( SOLI
Parcel Number. O•el.1&4 (a — q0
/ Type of Water System Reason for Application Q
PPublic/Community Water System(2 or more Building permit Z 0?6?-3
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 wail, check the PubliclCommunfty Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water system 7v p -(kvt lMi(�: Yj/ Z(jl a06 1
Name of Water System:
Water Facility Inventory(WFI)Nun er. mnr( (write'none'for two-party)
KI I am the manager of this water system.The water system has been approved 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(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)connectlon(s)without exceeding the
limits of the water system or any limits setby state
and local regulation.
Print Name of Water System Manager 1�� + ra Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www oo mason wa us.
r:va3 re�m,�p��swne _ aerise44rz�rzo21
.,/ Individual Water Well
yy Water well report(attached to application). Depth It �.r
Well capacity Test(attached to application) � gpm ?8VO pd.
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The well driller often performs well capacity tests at the time the well is 1mn3truoted. Results froD
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.
�I Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA h[tl2:lkqis.m.mason.wa.us/planning 14 15 16 22
Water use or limitation recorded................................... N/A Yes
Well Drilled............................................................... Date
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)
tfSatisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate su ly of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource r
Recommended appmval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Dete-,nWPr
O
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. ChaP-Ar
36.70A RCW. V
❑ Unsatisfactory Determination: OFC ) O
M�
Applicants water supply does not appear adequate to meet the needs of its intended use fo �23 reason(s). "/yENU/qO
M
Reviewer's Signatures: O✓A ENr4'hZ4tT8
Environ. Health: Date.
This form may be scanned and available for public view at yna.co.mason.wa.us.
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2205375 MASON CO WA
12/11/2023 10:39 AM NOTCE
FOBERT PRYSSE R193250 Rac Fee E204 50 Pages: 2
IIIVII IIIIII I II 11111111111111 I III lilt Pill 11111111111111 lilt lilt III Ill
Return To nn
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Grantor(s):(1)"'AOhiAl at (2)
GraMee(s):(1)PUBLIC
Legal Description (1) (1)+ 10 2ofiaaba
(Abbreviated form:i.e. IoK block,plat or section,township, range)
Assessor's Tax Parcel: (1) ri a 1 L) 4 - 1 a - q 0 1 0 1
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:
Maximum Annual Average Gallons Per Day: qc`n gallons
Dated on this I I—day of 7i z- , 20Z3
Signature of Grrantor(s):
(1) 111,01AL . (2)
State of Washington )
County of Mason )
Page 1 of 2
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I,the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this�day
is_V�__day of p! r�YN �,e 201a,
0-�64.r ,/�i.dLC. personally appeared before me,who is known to be
signer of the above i hume�knowledged that he(she)(they)signed it.
GIVEN under my hand and official seal th ay d year last '0
Notar) ublic in and f the State of Washington,
p�• .....
, .
p:l� so
ni, _ My commission expires: 5— GCS -27
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Yi7Ivys,
TF OF
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