HomeMy WebLinkAboutWAT2024-00158 - WAT Application - 3/20/2024 WA
MASON COUNTY
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COMMUNITY DEVELOPMENT
416 N 6-Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4 Better: (360)276-4487 ext 400 4 Elma:(380)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 acconnparry this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: /C70r//4✓13. Data.- -;Z0—Z.A
Mailing Address: 1:9G3 C. GeblvieZ S/ae!/o Phone: (3b6. 333 -e I-A4
Parcel Number: 32oZ2 - /2 —YOU 7-2
Type of Water System Reason for Application
❑ Public/Community Water System(2 ormore Building permit r)IL 7,l -to 6
connections) ❑ Division of land
❑ Individual water source (one connecton), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Sprine/surface water ❑ Other(explain)
bf Other(explain) E—
❑ Replacement or Remodel(please indicate name
H you have mot than on ty.Z.connected of water system below if applicable—no,
to this well, check the Public/Community Wafer signature required)
System box.
Part 2: Water Connection Information
v�2�ti`1- 0 poi�
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 connections) 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 wiling 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:01 Forms\Dnnking wafer Revised 1,75no 19
Individual Water WWell
`) Water wen report(attached to application). Depth V R
pl Well capacity Test(attached to application) W gpm�pd.
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.
QT Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://(iis.co.mason.wa.us/planning 14�15=16=220
Water use or limitation recorded................................... N/AQgYes
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 WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Tire 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).
-�,�� ��" '� R,ev�lewer'a Signatures: (�
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WELL CONSTRUCTION CERT6ICATION: I construdeE retailer accept raponsiWfiy for consuuttion of Nis well,and its compliance with all Washmglm we0
eanrbuctm MaotlaNs.Materiels aseel real Me informaioa repor mid above m eve to my lest luwwledge and belief
0Nite+0Traioee13PE-Pint Name Mark Moss, Drilling Comoanv RICNARDSON WELL DRIWNG
Siaaure Address PO BOX 44427
Li.No.2432 City,Stem,Zip TACOMA,WA 98448
B'TMWEE'Sponsor's Licpae No.24M Comm tire's
Sponre§Sivemre Reservation M.RICNAW32108 Date09;1N2022
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Persons wnh hmreng loss ton call)1lfor g'ashomoon Relay Service. Persons with a syee[h dembiliry can col1817833-6341.
2208788 MASON CO WA
03/20/2024 09 a8 OM WTCE
09 D COCCMI 0198981 Pa. Fee: 9304.00 Pages
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Return To
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G hELFuti WA CIS
Grantoe(s): (1) 'i�flUl • ` 121CKl (2)
Grantee(s):(1) PUBLIC .L
Legal Description (1) Lo 4 D f SV* 3152 -AF*� 2165Do Pm nu)nC
(?Abbrsvialedlorm:i.e. lot, block platorsection, township, range)
Assessor's Tax Parcel: (1)3L a b a 2---L 2-- o U " a
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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 andlor Water Resource
Inventory Area or WRIA.
WRIA: I � _
Maximum Annual Average Gallons Per Day: C-/6 gallons
Dated on this ?O day of Ma.z<) 20�.
Signature of 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 th ton is day of Hdxc1 , zq�,
DV fd �C 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.
`\"'%wk-L rrrrr Ad ,, Notary Pub in and for th tale of Washington,
��° .........f;01, residing atC t 9'✓1
Fis$ion F;•.O�'%
?Q Go�•M1,t-2e�:N cS My commission expires:
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