HomeMy WebLinkAboutWAT2023-00254 - WAT Application - 9/21/2023 WAT��-�''�
MASON COUNTY
COMMUNITY DEVELOPMENT
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415 N 6-Street,Bldg 8,Shehon WA 98584,
Shelton:(360)427-9670 am 400 O Belfair:(360)275-0467 ext 400 0i Elms:(360)4825269 am 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: AllrtloCrtf {Z1'64S Date: Y/2f/23
Mailing Address: 671AS- OWrNiic dr, UN:r#f Phone: ng/
Parcel Number: 7{q
Type of Water System J/ Reason for Application
❑ Public/Community Water System (2 or more Sir Building permit —bIGi2ZZ3.O114U
connections) ❑ Division of land:
0 Individual water source(one connection), #of Parcels? SPL
❑O 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 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:
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 (i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and wilting 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.
11EHF.m 1MnMo,Weser RevisM I125t2010
Individual Water
Well
Water well report(attached to application). Depth
®I Well capacity Test(attached to application) SO gpm ` yopd.
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:dgis.m.mason.".us/planning 1�15M 16[ ]22[]
Water use or limitation recorded................................... N/A r-1 Yesyy�
Well Drilled ............................................................... Date )Z
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)
l " Satisfactory Determination:
r\ 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 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applimnt's water supply does not appearadequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures: �{
Environ. Health: IVIl, ' \n"� Date
CSD Director: Date 2 of2
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Olympia WA 99502 RECEIVED
pARQgAep 360-967-7010
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2202472 MASON CO WA
09,21,2023 03-.01 PM NOTU
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Ni C, Q n� RIGG5 R191030 R.. F.. $200 50 Pa.- 2
6r2.r OUA"A'c, Delve, W,Ii-4 II II II I III IIII III�III IIIIII IIII I '.III
Grantor(s): (1) A "cHO"111f 12645 . (2) ZACH /CiGGt
Grantee(s): (1)PUBLIC
Legal Description (1) Lo+ 5 0C survey 15/l Oo s )�1T I -5
(Abbreviated form:i.e. lot block Plat orsecbon,township, range)
Assessor's Tax Parcel: (1) L��O
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 orWRIA.
WRIA: I t
Maximum Annual Average Gallons Per Day: 550 gallons
Dated on this ?il S day of r6Pre RV4- . 2077 .
Signatuy Grantor(s):
(1) (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�,'�kGYY1�✓ ,20 jZ
r 6v..ia Rion G personally appeared before me,who is known to be
signer of the above instrunient land acknowledged that he(she) (they)signed it.
GIVEN under my hand and official seal the day and year last above written.
���0r
�.•'p�{p1E M Notary Public in and for the State of WashingtJn
t'NOTARY": ,; residing at S AD IL fi
21009497 - My commission expires: D bZ5
Nam:• PUSUC '2?
"4,Ou WAwd��O
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