HomeMy WebLinkAboutWAT2024-00047 - WAT Application - 12/27/2023 ` WAT
MASON COUNTY
COMMUNITY DEVELOPMENT
Ibmlt NslsUnx QnW,,emlmry.vlronlry
415 N 6-Street,Bldg 8,Shelton WA 98584.
Shelton:(360)427-9670 ext 400 a Belfair:(360)2754467 ext 400 4 Elms:(360)482-5269 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 she plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: ray Date:
Mailing Address: PQ, go%( 1 41 Phone: 360-106- 9`1SZ
Parcel Number: 421tq_23- 90633
Type of Water System Reason for Application �,'1
XPubliclCommunity Water System(2 or more Building per I-�a;
permit B �O 4-OOi V4
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
N you have more than one residence connected of water system below if applicable—no
to this well, check the Public/Community,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: UJFLZOz3,0x 5s Urj(
Water Facility Inventory(WFI) Number: r)0nI—
T
/(write'none-for two-party)
16 I am the manager of thi water system. The water system has been approved for Z services.
There are presently connection(s)in use.This will be the A onnection.
❑ 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 hull 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. c.!
Signature of Water System Manager Date
i
I
This form may be scanned and available for public view at www.co.mason.wa.us.
Jt1EH FmmsA DnNing wow I1--d 1/2i101 A
Individual Water Well
® Water well report(attached to application). Depth Sol?) ft. Q,
IN Well capacity Test(attached to application) K gpm yb C)apd.
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.
IS Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hftp://gis.co.mason.wa.us/planning 14V'�15=160220
Water use or limitation recorded................................... N/A F-1 Yes
Well Drilled ............................................................... Date (G/ 1 )
Individual Spring/Surface Water
❑ WDOE perk(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 detennination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee cempliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A ROW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reasons).
Reviewer's Signatures: s..�
1 Environ. Health: Date
CSD Director: Dale 2ef2
1
1
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® ConNuctioo Water Right Permit No.
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��EoNaer 7nmro Nme(rwa)dale.pna ailbuit Company KNAPP DRIUNG INC,
DrE1mIDa�er7lnivm Siansaee AddW ME Lam Or
D�IrroaaslJemr No.3921 City,Bret,zip shltm Wet 995M
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Thurston County Environmental Health .
2000 lakeridge Dr.SW •Olympia,WA 98502
360867-2631
niunsron muwrc
COLIFORM BACTERIA ANALYSIS
Dale Sample Collected Time Sampe County
Corrected�2��23 .2-30-p- Jnason
Typeof Water System(check only one borJ dvate Household qq
❑Grohl ❑Group& �ONer ek
Group A and Group B Systems-Pmenew from Water Fadlites Invenlay(WFIr
D9 _
System Name.
Coclad Perm¢
Day Phone:( ) Cell Phone:camog J�
E-mail:' '� Eve.Phcaa:( ) -
5^Mr IrI eaJtlress of eaepenal ffij'rej�,�.''
SAMPLE INFORMATION
Sampbwllededby(naned i e—T+le- F-i
Sawed.OCaq3.eaddem"am Sample collected $pfallnNem..rememahm:
6110- A d
Sbdf-9n J1Ja . 985gy
Type of Sample(court check only on box of911hrough W listed below)
1. Dull..DhArlbutbn Sample 2.Repeal Sample(after munt.routine)
Chdrinaled:Yes_No ❑Disidbuton Stand
Chlonne Readmit Tool_Free_ Chlorinated:Yes_No
3.Raw Water Source Sample Chlonne Resdual'Tolel_Free_
❑E cop-OWR(A)P)
❑Fecal-s ,,GWl,rpnos f—orienl Unsatisfactory roNdm lab number
DIle�ed:YW_No_
❑Marnsmam Writer],(AP) Unsatisfactory moth collect data
❑Other
9.0 Sample Collected for Information Only
Investige4ve_ ComlmNan lRepaks_ Other_
LAB USE ONLY DRINKING WATER RESULTS to USE ONLY
❑Unsatisfaotory,Tote)Colibml present and Satisfactory
❑Ecek present ❑E.cokmeant Norm deleted
Replacement Sample Required: r
❑Sample be old(>w hours) ❑TNTC Cl
Baderial Density Resulb:Tolal Colibr _...__1100ml. Ecart 1100m1.
Fecal Coliform 1100m1 Enlerocoszi 1100 mi.
Method Code: SM9223B ❑SM 9...0 GWead TrnaRac ned D
SM 9215E ❑Entredert0 - - -3 in
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Return To 2206206 MASON CO WA
I .J'v ry �fy IIN IIIIIII0II2II6II II,N,N:I IIINFP NOTCH FRY #193
910Ree Fee:
1304,50
60 Pages ]
I Ill IIII11lull1NIIIIIIN II
I III 011
Grantor(s): (1) Ttff ru )Ur F✓., , (2)
Grantee(s): (1)PUBLIC
Legal Description (1) L.OI .3 of 5i' it I(r2O
(Abbreviated form:i.e. lot, 'b'1llock,plat or section, township, range)
Assessor's Tax Parcel: (1) 4 a -Qi -�L-0—3-3
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: 1L gallons
Dated on this 12 M day of Jec c.nho✓ 20 ? ti.
Signature of Grantor(s):
(1) (2)
State o as ' gto )
County of Mason )
Page 1 of 2
I, the undersigned, a in Notary Publi and for the above named County and State, do hereby
certify that on this_f�yf,day of. m , 20 ,
t P (jrq Y r Nr personally appeared before me,who is known to be
signer of bove insins etn�knowledged that he he)(they)signed k.
GIVEN under my hand and official seal the day and
year last above
written.
yl
ANNETTE H MCNEIL / �c"""""Tr • "/ C" +'
Notary Public LN Public in and-for the Late of Washington,
State of Washington
License Number 198039 residing at
My Commission Expires
March 15,2026 My commission expires: A&CA
Page 2 of 2