HomeMy WebLinkAboutWAT2024-00101 - WAT Application - 2/26/2024 I WA'rIL2. -- ao i o 1
MASON COUNTY 415 N.6-Sp
Shen .WA 99584
6 COMMUNITY SERVICES Shettm,:360-427-9670,Exc400
Belfiv.360-275-W7,E 4W
a v'a++een.o �.,ix.me.cn nrrusm Elms:360482-5269.&L 400
Application for Determination of Water Aaequac,
1. ConWlate Pert 1. No determination can be made until Part 1 is fully completed
I2, Complete only the portion of Part 2 applying to the type of water connection utilized.
t3. Submit completed application,with any required aftechnnents for review.
14, An approved building Sao plan must accompany this applimii
Part 1: Applicantl Parcel Identl`ficatillin
Name on Applicant: ✓\�, J. {'�' lWj cl�, Data: 2I7_4I202.4
Mailing Address: Z I S t W�I,l O W `..y4(-4Ahone: `7Y9�32'1-3�1�I�I
Parcel Number: 'S , •(1 >�' '] j G} V C ,;,�
Type of Water System Reason for Applicatlon
❑ PubConniGe/Coon mmunity Water System(2 or more Building per ink ti 142D24- WA)Ne
ivision of land:
*individual water source(one connection), #of Parcels?_ SPL
may" ❑ Boundary line adjustment
❑ Spnng/surface water
❑ Otherfeuplain) ❑ Other(ezpiain)
ff you new cows Om one resitierico ❑ Replacement or Remodel(please indicate name
.r.ynM a water system below ITBppnCaOle--.
to this wan, check the.ta__.-Com.^un.,•za:a:
Part 2: Water Connection Information
Complete the section appropriate ror the type of water connection being evaluate,
Name of Water System:
Water Facility Inventory(WFI umber: (write'rane'for two-party)
❑ Ian the man r agar of pile tam.The vr�rfer system ha n approved for services.There
are presently 'on(s)in u This wia be tlk ( connecaon.
/s¢ / T—
❑ I am the manager of
Is' system.This cyfinection willi`t.c=r1 upgrade or change the use of an existing
connection on this syatem h.e.:recrainot to fug ti�_ on the fallowing line the nature of
this change: // -
This water system is able and witling to provide water to this(these)connecgpn(s)witheui
limits of the water system or any limits set by state and local regulation. I
Print Name of Wafer System Manager Phone !
1 Signature of Water System ivanageI Oche !
This corm may be scanned and avairabre ror pYmic view R W niff&U rbee
-vim..,
Individual Water Well
' Water well report(attached to application). Depth it.
-K Well CaPacity Test(attached to application) b apm opd.
The well driller often performs well Capacay tests at the bme the well is constructed. Results from
these tests are noted on the water well report. ResWts from these tests will be accepted. fifth ter
well report cannot be located by the applicant or if the water wail report does not have a capacity test,
a well CsPacity test,which Provides stabilization of dmw-down and recovery data,must be Perm"--
by a licensed oonvacax.
xaadsfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIp)
t
1 Development within which WRIA hnp_!/n,,Is.cn mast.^..are.u=lmmno 14 is 16_22_
Water use or limitation recorded......................--......... WA Yes
`Nell Drilled —........__..........................._................... OWe
Individual Spring/Surface"INatat
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source can provide at least d(iu ganons per aay;andlor
Provides water at a rate of 2 gallons per minute based on the following observations. 1
Author of Statement Data
I Refatiorshio to Acc:; '
I
Part 3: Mason County Community Services Evaluation (stall use only)
Satisfactory Determination: '
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water bdefindely in Me future or guarantee compliance with at applkable WDOE water resource
- , , P . . eerrmegnaulaftwoosf.p^ " ' -0 I
1 Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
as me o
u Unsadafadory Determination �
reeecn(s)s water supply does not appear adequate to meet the needs of its intended use for the following
�— ` /V�10ReoyV Isslgnaturoa:
Environ.
Hearn: Date
mz=Totm may be scanned and available for gitab is view at waw�myji&
WATER WELL REPORT " aevna:Mfrv* or Nm:x MinmMNa WE34025
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PO BOX 2227
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Thurston Co"my Environmental Health
2000 Lzke eseo WA 93502
3609672631 --ills b 1
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2209141 MASON CO WA
0312912024 11 20 AM NOTLE
Ret I To j
II NALD MARSIAIIL #19623, 40 INllllllll�l,ll 11l 2
I
Grantor(s):(1) o VA4b f/ MdT's6s ) i , (2)
Grantee(s): (1)PUBLIC1
Legal Description (1) LD+" I 5P4f-ab1--1.-inT-TV-5-A 5 '%zIo
(Abbreviated reran:i.e. lot, block plat or section,township, range)
Assessor's Tax Parcel: (1)4L 2 D 3 5 - r] ,5.j! 0
sa.�--rA6- /
TITLE NOTIFICATION OF WATER RESOURCK7E INVENTORY AREA(WRIA)
I (We), the undersigned granlor(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 6.66. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area orWRIA.
1
WRIA: 1`
Maximum Annual Average Gallons Per Day: _ '145rD gallon
Dated on this A {4 day of 7;Y1 b A- 1, .20 Z*!
Signature of Grantor(s): / ,t
State of Weshingh7n Pr ✓+A )
County of Maim N%nA� )
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 5_day of AA O, 'Olk . 20 7-1 ,
W-�n 41 Mtir ti'aV H 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 ear last above written.
�— Public in and for the State of WaeftingMrr,
-w wari rrwrus c[ex�gor
residing at y Vl v A- -
r�r�r
M bow ,Iyif mn My commission expires: A H� �Z
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