HomeMy WebLinkAboutWAT2024-00125 - WAT Application - 3/6/2024 MASON COUNTY wnT�2 - Ob/fa?
�NZ COMMUNITY SERVICES
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�1V` 415 N 6B'Street, Bldg Shelton 4 98884, RECEIVED
Shelton:(360)427-9670 ezf 400 t• Belfair.(360)275-4487 eM 00 4 Elma:(360)482-5269 ex1400
FAX(360)427-7787 MAR - 6 2024
Application for Determination of Water Adequar5 W. Alder Street
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: S 1 e��a ��.5� Date:
Mailing Address: ,$r(S N/lQ�l /Vir�1UQ .I t7✓ Phone: 360 .3s9-/GJ3
Parcel Number: 57ze)o j22rMl3gd
f,f Type of Water System Reason for Applicc�a//t�ioo�nj�� M•�
ip�Wlblic/Community Water System (2 or more •�-Building permiteL,19AA "W3D@�
uu connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcelso SPL
❑ Well ❑ Boundary line adjustment
❑ Sprin surface water Other(exp ❑ Other(explain)
lain) 2fjC2 Cinkt'lroia�
❑ 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 Public7Community Water signature required)System box. ? Y �ZCk
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.
❑ 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.t H Fmms\Dunking Water Rwis 1252m8
Individual Water Well
Water well report(attached to application). Depth�\41_ft.
Well capacity Test(attached to application) �;'C3 Pm npd
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
sba licensed contractor.
atisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hftp,//qis.co.mason.m.us/planning 14ED 15=1r[=22;
Water use or limitation recorded................................... N/A=Yes$
Well Drilled ............................................................... Date
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.
❑ 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: L (I1012"1,1 I
Environ. Health: llo �V\ Date
CSD Director:
Date 2 of 2
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MAR - 6 2024 ENVIRONMENTAL
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2208273 MASON CO WA
03:0612024 02:
11 PM NOTCE
STEVE TUPPEF N195593 Reg Fee $304 50 Pages. 2
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HEALTH gL�aOa�-6bJ o'Z
Return To
S-kV!L f �,— RECEIVED
A/A��s�l Oi
wKl 9pzz MAR - 6 2024
615 W. Alder Street
Grantor(s):(1) (2) .
Grantee(s):(1)PUBLIC
Legal Description (1)TR 33 OF GOVT LOT 4 & NW NW S 50/151
(Abbreviatedform:i.e.W block Plat orsectton, township,range)
Assessor's Tax Parcel: (1) 5 2 0 0 8 _ 2 2 _ 0 0 3 3 0
TI 8,T R f
TITLE NOTIFICATI ON 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: 22
Maximum Annual�Average Gallons Per Day: 03000 gallons
�2
Dated on this `day of "T
Signature of r(6 '
(1) (2)
ate of of
)
County of Mason )
Page 1 of 2
I,the undersigned, a Notary Publi ' nd foorlfhna above r��pled County and State, do hereby
certify h t on this "day of ([(Ll�
personally appeared before me,who is known to be
signer of the above instr.irfiefirt, and acknowledged that h.(she) (then fined it.
GIVEN under my hand and official seal the day a ear st abo an.
O` ,gFSe
R K[BHp4
``` .•�;y910M•p�•n..�N�y otary Public in nd fo ate of W shington,
NOTARY V7% residing at
_ 23038426 _ My commission expires:
PUBLIC
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