HomeMy WebLinkAboutWAT2024-00155 - WAT Application - 3/5/2024 &l £L2o,22-ooGdz WAT
415 N.6k Street
MASON COUNTY Shelwq WA 98584
COMMUNITY SERVICES Snetwit:360427-9670,at.400
BeHah:360-2754467,Bzt.400
mra�srsnnksem.a,m.�x�Hemv reraauy Heelro ms El :360482-5269,Ext.400
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 t: Applicant/ Parcel Identification
Name on Applicant: 4UC, <5`L e 464,,1 Date: 2°7-/
Mailing Address: PO i 3?4d ' 57./4 Phone: OZUr
Parcel Number: .7200R- 42— Qiu/go
Type of Water System Reason for Application � 7
❑ Public/Community Water System(2 or more {�Building permit 13Lb"`;4-00J—iA
connections) ❑ Division of land:
❑ Individual water source(one connection), 0 of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
Other(explain) ❑ Replacement or Remodel(please indicate name
Hyou have more than one residence connected of water system below if applicable—no
to this well, check the Public/Community,Water signature required) 006 Z
System box n t(1
Part 2: Water Connection Information i�o .� 2
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)
❑ I 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 (Le.: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.
l:\FH Farms\Drinking water / eevised4:4'2018
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/�^�'��"'' Individual Water Well
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gemater well report(attached to application). Depth � � ft.
r-//y/�1 Well capacity Test(attached to application) so gpm 7`? �gpd-
I 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 htto://ois.co.masonma.us/olanninc 14-X15_16_22_
Water use or limitation recorded................................... WA Yes,
Well Drilled ............................................................... Date lb L
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,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: 2 y
Environ. Health: 1 Y�r' `�� Date Ji, tl 1
This form may be scanned and available for public view at www.co.mason.wa.us.
Paye 2 of 2
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2000 Lakeddge Dr.SW !Olympia,WA 98502
360 867-2631
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2209005 MASON CO WA
03/3612024 02 44 Vn NOTCE
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Grantor(s):(1) �ii.�2nil C s fz y (2)
Grantee(s): (1)PUBLIC
Legal Description(1)TR 16 OF W1/2 SE TR 2 OF SIP#706
(Abbravlated form:is.lot block,plat oraacflon,lownsblp,rNW)
Assessor's Tax Parcel:(1) 3 2 0 0 6 _ 4 2 _ 9 0 1 6 0
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 6.66. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: 14
Maximum Annual Average Gallons Per Day: 950 gallon
Dated on this LPLal� day of Nldl,y(�1 ,,•20 .
signature of G ntor(s):
, (2)
State of Washington )
County of Mason )
Page 1 of 2
__j
I,the undersigned, a N tary Public ii and for the above naryed County and State, do hereby
rli that on this r day of Nf/�1 20-=,
i enionally appeared before me,who is known to be
signer of the above Instrument, and acknowledged that he(she)(they)signed ft.
GIVEN under my hand and official seal the day and year laaAstt^above a rift .
!P
AI av'l—
Notary Public in d for the Ste l of ashington,
TERESA L WAY residing at M
Notary Public
Stets of Washington My commission expires: s
Lie 0Number 135601
My Commission Expires
Ms 15,2024
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