HomeMy WebLinkAboutWAT2023-00365 - WAT Application - 12/20/2023 WAT ZA3 -�ry�
MASON COUNTY
COMMUNITY DEVELOPMENT
r mitns:ironaf nW,smimre,Punninr,
415 N 6-Street,BWg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 O Belfair.(360)275-4467 ext 400 a 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 site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Tracy Hanson Date: 12/20/2023
Mailing Address: 120 Vista View CT. Shelton, WA Phone: (360)790-8225
Parcel Number: 32030-32,Wl-1 'i Ob 1 1
Type of Water System Reason for Application/
ElPublic/Community Water System (2 or more I7 Building permit tva6;�7-0161-
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
O 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 Public/Communify Water signature required) _G2
System box. vU
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of water System: Barber Water System
Water Facility Inventory(WFI) Number: None
(write'none'for two-party)
O I am the manager of this water system.The water system has been approved for 2 services.
There are presently 1 connection(s)in use.This will be the 2nd 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 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 12/20/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
I:WI Forms\Drinking Weta Rcviscd:/25/2018
Individual Water Well -Occob
0 Water well report(attached to application). Depth 212 ft.
El Well capacity Test(attached to application) 15 gpm v/ A A vim l 1�0 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.
El Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://ais.co.mason.vra.us/olanning 14015=]16[-L—]220
Water use or limitation recorded................................... N/AJ=—Yeses
Well Drilled ............................................................... Date 06/03/22
Individual SpringfSurface Water
Oermit(attach to application)
❑ MethoE pd of dish
El I have reason to believe tatcaneat least 800 gallons per tlay;and/or
provides water at a rate on t wing observations.
Auth Statement Date
ationship 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,orguarantee compliance with all applicable WDOE water resource regulators.
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.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
c'R,e,,viiewer's Signatures:
trn� ,
Environ. Health: 1 `J -- ' Date
CSD Director: Date 2 of2
3
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2205743 MASON CO WA
Return To HONSON3F1935]2 flecHFeeTO$204 50 Pa9er 2
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Grantor(s): (1) (2)
Grantee(s): (1)PUBLIC
Legal Description (1) L F I o f p Z54 a A En-* (00a4A"I
(Abbreviated form:i.e.lot, block,plat or section, township, range)
Assessor's Tax ParceL• (1)� QiLIZ- �-G d ) )
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: I� //'�/
Maximum Annual Average G-allllons Per Day: `I%C gallons
Dated on this U day of -✓eumbG✓ 202151.
Signature o rantor(s),
(1) (2)
It
State of Washington )
County of Mason )
Page 1 of 2
I,the undersigned, a Nary Public in and for the above named County and State, do hereby
certify that orr''this.12p_day of-\�°CCMbW , 2023 ,
TYA W 1}/rrS orb personally 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"`pPAN n �q�pi
Notary Public in and for the State of Washington,
��w�+m .
? residing at rKQSe n �e�n • 7
er- a My commission expires: 11I 2�t�Z6
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