HomeMy WebLinkAboutWAT2024-00075 - WAT Application - 2/7/2024 WAT
MASON COUNTY sb�aw 985594
COMMUNITY SERVICES Shclton:360427-9670,Bxt 400
Belfair.360-2754467,Bzt 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 approved building site plan must accompany this application.
Part 1: Applicant/Parcel Identification I'
Name on Applicant [t,�f elLt-1 h�L Date-, ;ii,- r]- 2 0 Z-1
Mailing Address: 146 [3jip-I M -3,2iQ l
Parcel Number: yL- A 3 K10 - 14- 40130
Type of Water System Reason fore Application -
pQ Public/Community Water System(2 or more ❑ Building permit 0076244 -661(A6
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ ReplacOther ement)
❑ 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. C/
Part 2: Water Connection Information �23 COa (J
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: 41+' W a. L
Water Facility Inventory(WFI)Number. ho"5 (write"none'for two-parry)
XI am the manageAf this water system.The water system has been approved for a services.There
are presently l 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. �f�� Q,. 2
Print Name of Water System Manager - �1�f�� Phones (d)-q?)0--3
Signature of Water System Manager 1`"�— Date 2L 7-1
This form may be scanned and available for public view at www.co.mason.wa.us.
]iFdf F®s\mamegw.ca Revised 4f2 =1
Individual Water Well
.Water well report(attached to application). Depth 1 ` ft. Q �
Well capacity Test(attached to application) pm 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.
�yy Satisfactory bacteriological test(attach to application).
/' Water Resource Inventory Area (WRIA)
Development within which WRIA httpJ/ais.m.mason.wa.us/plannina 14>!�15_16_22_
Water use or limitation recorded................................... N/A Yes
Well Dnlled ............................................................... Date V I
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have mason 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,Titre 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
3670A PICK -
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its Intended use for the following
reason(s).
�,,�Reeviewer's Signatures:
Environ. Health: �W ^ Date J 1 "�
This form may be scanned and available for pubfic view at www.eo.mason.wa us
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Thurston County Environmental
2000 Lakeddge Dr.SW A Olympia,WA 98502 98602
360367-2631
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2207316 MASON CO WA
0210712024 02.13 PIA NOTCE
Return TO STPFC i194839 Pec Fee $304 50 Pa9es 2
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Grantor(s): (14rl n ha V 1✓-� (2)
Grantee(s): (1) PUBLIC / A
Legal Description (1) 1 IZ 13 o F /2 Sec-ho n /(7JWP I q_ 9-
(Abbreviated!form:i.e.lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) L�� D - I �- D O 3 U
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: 14 C/T
Maximum Annual Average Gallons 11Per Day: I N gallons
Dated on this day of 20_.
Signah' rant
(1)� C (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 tha on this day of 20
Cc Q.V personall ppeared before me,who is known to be
signer of the above instrument, and acknowledged that h sh (they) signed it.
GIVEN under my hand and official seal the day and year las above written.
NlqLaryPublic in and for the State of Washington,
Nv'�R'9(i''�, residingat� (U,+L
JLJ:'"Sion��;.. ���/ /
h:'F�1.16Y026 i•'.
My commission expires: 61
_ NpTARY _
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