HomeMy WebLinkAboutWAT2023-00314 - WAT Application - 10/30/2023 WATa m 00314
MASON COUNTY
COMMUNITY DEVELOPMENT
Pwm¢aaslame 0,t ,,suIminr,Pmnnins
415 N 6"Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ex1400 + Belfalr:(360)275-4467 am 400 <" Elma:(360)4825269 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: Applicantl Parcel Identification
Nameon Applicant: Mar*,aLAAe W;tSon-6utme Date: to 130 Ia6a3
Mailing Address: L '�. G ur„in. f siniu h, rA Phone: Z5 3 —L t4 -29 is
Parcel Number: '^'er I u q=
3Lo3o - 14-ooIS0
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more El Building permit gib;o*3-9j316
connections) ❑ Division of land:
El Individual water source(one connection), #of Parcels? SPL
El 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.
Part 2: 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(WFI)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.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system (is.: 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.
t:�eimnv1 DdstiPR Waln RtAtW IRS12018
Individual Waters Well
'Water well report(attached to application). Depth--a ft.`
I` Well capacity Test(attached to application) \S opm / �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.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http:/Igis.co.mason.wa.us/planning 14,p 15016=]220
Water use or limitation recorded................................... N/A_[_I_Yes-&L
Well Drilled ............................................................... Date Z 1 LV
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)
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,Title 6,Chapter 6.68.0404)etermination of
Adequacy for Building Permits are satisfied, Additional Growth Management requirements may apply. Chapter
36.70A RCW.
L_ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of as intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: Date
a CSD Director: Date 2.f3
WATER WELL REPORT 10 DEPARTMENT OF Notice of Intent No. WE36395
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Vanguard Laboratory
2635 Parkmont Lane SW,Suite A 1� 5
Olympia WA 98502
VMX.,A{o _... 360-967-7010 - I (I �r�rM 01
COLIFORM BACTERIA ANALYSIS FORM W
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2203920 MASON CO WA
10/30/2023 02.00 PM NOTOE
WILEON-GUM, N102111 Rec Fee: $200.10 Pases. 2
Return To
Mac;ann¢ Wr1Son- Gumm
212. C.04lYIT� Es+u+u Dr. W•
Roan;E,y WA g857(p
Grantor(s): (1) MdlvrtlnwP Wi Jl;am r Um (2)
Grantee(s): (1)PUBLIC 530,`ra0, R 3
Legal Description(1) PU 1 OF ALA itOS 37 AF# ims"s PTA/ SE NE
(Abbn;viatedform:i.e.lot block plat or section, township, range)
Assessor's Tax Parcel: (1)-a-Q 3-Q-
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:1
Maximum Annual Average Gallons Per Day: �50 gallons
Dated on this 'JO day of 20 2 .
Signature of GmMor(s):
(1) YV1Cy QYWIe Ixl \SS`Y1- Gr yin vNn (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 day of l`JC'�' 20-1 ,
-Q,/ /xf ul, nYie A):.R-�ersonally appeared before me,who is known to be
signer of the above instrument and acknowledged that he(she) (they)signed it.
GIVEN under my hand and official seal the day and year last above written.
P`.N nGO�iq P. .-�" 0- 0
.F.. Notary Public Aand for the State of Washington,
e �� ��.ARY 9''••: residing ate 2�I A i nQQCAY•
m:n' pt/BL N 3 My commission expires:
7 mom •_
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