HomeMy WebLinkAboutWAT2024-00147 - WAT Application - 3/14/2024 �-�—
MASON COUNTY WAT
COMMUNITY SERVICES
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415 N 6-Street,Bldg 8,Shelton WA 98584.
Shelton:(360)427-9670 ext 400 4 Belfair:(360)275-0467 ext 400 1i 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 f: Applicant/ Parcel Identification
-- ,1
Name on Applicant: RDnne b �IS I.C� Date: 3/14 120
Mailing Address: 1)0O L Ohtll'x lalu l,lop Phone: i�- '�17,
Parcel Number eke noe-51_09De/)
Type of Water System Reason for
r Application
[IPublic/Community Water System(2 or mom ,Building permit T/1�F1�
connections) ❑ Division of land:
Individual star source(one connection), #of Parcels? SPL
127 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 Pub!WCommunily 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 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\EH Forms\DnnE gwater Revised 1/25a018
Individual Water Well
�5 Water well report(attached to application). Depth 65 u�A��9�20ty
Well capacity Test(attached to application) S gpm > r OO 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.
`1 Satisfactory bacteriological test(attach to application). V7071 i
Water Resource Inventory Area (WRIA)
Development within which WRIA htto flais.co.mason.wa.us/glitaning 14�6 15016=22=
Water use or limitation recorded................................... N/A=Yes-[YLAFVZZ(
2iBSK
Well Drilled............................................................... Date T 4L
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 33: Mason County Community Services Evaluation (staff use only)
t� Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the tuture,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.pply. Chapter
3670A RCW. P
❑ Unsatisfactory Determination: 1 i^
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following V
reason(s). q()G O
M4SQi C r- 120
Reviewer's Signatures: �Nn'f
Environ. Health: Date
Z 6 OJq NWN CNfq(TN
CSD Director:
Date z orz
WATER WELL REPORT DEPARTMENT OF No4ce of nmt No. WE07954RD
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ID Daillm Cl inee❑P Paint Nmve MADI TROTTER DNf.Caaa,aay COOLWATER DRILUNG INC.
Si yrc Add se 10921 NW HOLLY RD
License No. City,State,Zip BREMERTON WA 9WI2
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877-833-6341.
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" 2213846 MASON CO WA
11111/Y024 e9 09 11 NOTCE
. IIIVIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIullllle. 2
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RFCE) F�016 JUL 3 0 2024 D
By
Grantor(s): (1) /'rr �'VY , (2)
Grantee(s): (1) PUBLIC I ` ' p
Legal Description (1) P 17r 1) / Y/1S L A tt D1 V .2 ��t7✓
(Abbreviated fo/r�m:i.e.lot block,plat or section, township, range)
Assessor's Tax Parcel:
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: 0150
0 gallons
Dated on this da f 20—
Signature of G ntor '/ /� r,
State of W shi on )
County of n ) -
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 A 911,day of -1.A y , 203y_,
m . bue� _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.
NMMh,ry/,ryry a p iQ,l�.d
Notary Public in and forth State of Washington,
i •.,O', residing at rsrpy..n P, F,tc-G 4ruwfu cSq
r NOTARY
•'; My commission expires: Marco.r. 2 d?-D
aN� �BUC �Ei
'•p�•'•NEXPIRF•i�'•' �?•
•�'"rG,',c WASH\NG�,:
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Page 2 of 2