HomeMy WebLinkAboutWAT2024-00148 - WAT Application - 5/14/2024 WAT QOI 8
MASON COUNTY 415 N.hon,W Strew
Shelton,W98584
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Shelran:30427-e670,Ext.t. 00 4
Public Health & Human Services Eelrxir:36ans44s1,Exc4Woo
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:�E Data: 5� J' 202`i
Mailing Address: 4ffi liki Phone: _14
Parcel Number: 111,lhm WA C1
Type of Water System Reason for Application 2r, tI //
XPublic/Community Water System(2 or more Building permit �jIQ�Z — 00J" lA bL)
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 Pubfic/CommunAy,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 L&5170 Zti -000
Name of Water System OWW)
Water Facility Inventory )Number: 170 r t (write'none'for two--party)
1 am the manager of this water system.The water system has been approved for A 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 (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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.masoncountywa.9ov
J:\EFI Fomu\Crhikiag wrter Revix MSQ024 Paget oft
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
0/"Water well report(attached to application). Depth 5S ft. 5111-( ZUtiL
01 Well capacity Test(attached to application) 'S qpm 960 clod.
The well driller often performs well rapacity 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.
Cl Satisfactory bacteriological test within last year(attach to application). Z/Lf (70Z y
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 delenoination does not address adequacy of the distribution system,guarantee an adequate p 1 of
water indefinitely in the future,or guarantee mmpliance with all applicable WDOE water reaou
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040.Detannti
Adequacy for Building Permits are satisfied, Additional Growth Management requirements may apply. Cho ■ _
36.70A RCW. V
❑ Unsatisfactory Determination: MASQ MAYZ4 O
Applicant's water supply does not appear adequate to meet the needs of its intended use for
reason(s).
OJA NM yFA[
Reviewer's Signatures: G A[
` L/
Environ. Health: Date I
This form may be scanned and available for public view at vrww.masoncountywa.gov
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y' 2210774 MASON CO WA
05/14/2024 03.46 PM NOTCE
J ES'
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Grantor(s):(1) r
Grantse(s):(1) PUBLIC
Legal Description (1) 5G 5- 1 - l I Sec
(A6breviatedfo :i.e.b4 block,plat or section,township, range)
Assessoes Tax Parcel: (1)
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I (We),the undersigned gmntor(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.
WRL4
Maximum Annual Average Gallons Per Day: ` 4() gallons
Dated on this of� 20�.
Si ature G ntor(s):
(1 (2)
e of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a N t ,Public i d for the above narp¢d County and State, do hereby
certify t at on this a of , 20 2
10 pep onalty appear before me,who is known to be
signer of the above inst ent, and acknowledged that he( he) (they) sign d it.
GIVEN under my hand and official seal the day an ar la above wri
N tary Public I d o fate of Washington,
residing at
c e 23038426 = My commission expires:
tN� PUBLIC ,� `
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