HomeMy WebLinkAboutWAT2024-00035 - WAT Application - 12/12/2023 nEl] bY-hwch, ' &14A&V
wnT 202�- o00
MASON COUNTY S 'o 9858 I 1 A
COMMUNITY SERVICES Sheftm:360427-9670,Ext 400
Belfa r 360-2754467,Ext.400
aas.y H. En..mnen.I.. .C—.."NealM Eh.:360482-5269,Ext.400
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 Pan 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: Q6wh1CJ eA V-L�ne_ Cons} Date: 11-17- 3
Mailing Address: ZA 71 E Qti,'ll'a Lk Lk (() Phone: 36o -416. 4221
Parcel Number: ZZ004. 75'- 0816n
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit I!Sld ZOZ3- O 15`IL4
connections) ❑ Division of land;
Individual water source (one connection), #of Parcels? SPL
pA 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.
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 connections) 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EHF..\Drinking Wm R....cd LM2018
Individual Water Well
)i Water well report(attached to application). Depth ft.
QO Well capacity Test(attached to application) 145- gpm 8U� opd.
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 connector.
G( Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA
Development within which WRIA http:flgis.m.mason.wa.us/Olannino '14Y�',5 � 116_22_
Water use or limitation recorded................................... NIA Yes.l�
Well Drilled ............................................................... Date J
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 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 W DOE 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 RCW.
J Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures: �/ t ,r
Environ. Health: Date v M (LL
This form may be scann and available for public view at www.co.mason.wa.us.
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WATER WELL REPORT io DEPARTMENT OF Nate of Intent No. WE48791
ECOLOGY Unq F olog WeII ID Tag No. BPF073
TTpe « ge cfWY: sta.ofwazMnon
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WELL CONSTRUCTION CERTIFICATION: 1consuuctedMallow accept responsibility for cavvtr oa oftks well,wd iD canplimme with all Wadlinghn well
erngMYlan 9Wdads.Materials uxd and l!w information reporlW above ere tme m mY 1m91 knowledge and belief
R Driller❑Treat.❑PE-Pant N 0 Ph ken Dolling CompmW Arcac is DrAi g Inc.
Sip Address PO Box 1790
license No. 2053 Ciry,Sim,Zip Shelton,WA 98584
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2206944 MASON CO IAA
01/2912024 12.3; MFl 01CCE
Return BOVSRLEY 419453 R.
Fee 5300 BO PegSs 2
IIIIIIINIII IIPIi1IIIIII11i III V1IIIiI!IIIIIII
3 ±. v SVv
Grantor(s): (1) ", Al,-, fT uShl, (2) XS2 l,asmto Stio
Grantee(s): (1) PUBLICS ,./
Legal Description (1) 1��2� 2-VV�Izt,+ ll��l'� 5�b3
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 2 2 2 �L-2 S - O O —L l� 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 Arlea'Ior WRIA.
WRIA:
Maximum Annual Average Gallons Per Day: 50 gallons
Dated on this day of ayl.tn,'t-r�r , 20�.
Signature of Grantor(s : �'�"`� T
(1) C. (2)��-..
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a No�ary Public in and for the above named County and State, do hereby
certify that on this aAP day of Shu , 20 'dK ,
4.rh, 4 Elmo ga„hle., personally appeared before me, who is known to be
signer of of the above and acknowledged that he (she) (they) signed it.
GIVEN under my hand and official seal the day and year lastabove written.
Uc119vgallotary Public in and for the State of Washington,
7
nQfonresiding at 1`!do ��+ �'�'^"� �Ivt lf) ��.+,w4 of 5572eY 0,2075 My commission expires: r/Y 1d,—
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