HomeMy WebLinkAboutWAT2021-00280 - WAT Application - 6/24/2021 t Y
RECEIVED
1UN 24 2021 wAT U21 - 002ZO
615 W. Alder Street 415 N.6°Street
MASON COUNTY ANVIRONMENT& ,,. Shdm,oA
'MMUNITXSExylC HEALTH B"'�v3fi0.Y/5-0467 400
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Application for Determination of Water Adequacy
Instructions
i. 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 1 ^
Name on Applicant: n avt J t7,ft%.Jn Date: W-2,4- 202-1
Mailing Address: p0. (fey 71q /�A WQ ZZYSOPhone: 360-9419-50"
Parcel Number: f29' zZ' 9�yD
Type of Water System Reason for Application
❑ PubliclCommunity Water System(2 or more Pf Building permit`biel z6z I - 00`fl30
connections) ❑ Division of land:
Ill Individual water source(one connection), #of Parcels? SPL
9 Well ❑ Boundary line adjustment
❑ Spdngtsurtace 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 PublicVCommunity,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-parry)
❑ 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 publk view at www.co.mason.wa.us.
kwil tame\priming Wwer Revised M4lJll 18
Individual Water Well
❑ Water well report(attached to application). Depth 203 ft.
❑ Well capacity Test(attached to application) gpnn 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.
❑ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area(WRIA)
Development within which W RIA http://ciis.m.mason.wa.us/i)lamft 14_15_16_22_
Water use or limitation recorded................................... WA_Yes_
Well Drilled............................................................... Data
Individual SpringlSurface 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;andlor
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 6.6e.040-Detemtinafion 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:
Environ. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
P.,2 nr2
ENVIRONMENTAL
HEALTH 2160224 MASON CO WA
L"I"2t 595I35Reoe FeeT $,Is 50 Pagas
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Return to:
'DAVA i& RECEIVED
y "7221
F)g IQ.n_.LOA `t8628 JUN 2 4 2021
615 W. Alder Street
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I(We),the undersigned greduc s),hereby place ibis notice on record that the following described real eatum situated
in Mason County,State of Washingmn;to wit:
OR
Subdivision Division Lot ��rr Range Township Section
and having the Tax Parcel Number of. 10ii-SR't —alas — 400a-I h
is subject to water use restrictions and conditions ad by Washington State Senate BIB 60YI 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:U Maximsoum Annual Average Gallons Per Day: 15�
Dated on this,�_day o(//�/ 6/G//7(G�/t ,2200,Z
SignatureofCmantor(s): 'L/ffa��—r / '/• M/
PriniednemeofC,rantor(s)' DtJ J_ E
Grantee:Public
StmeofWashington )
Coun y of Mason )
L the undersigned,allomy,Public in and for the abovenamed County and Stat4 do.hereby certify that on this
11r `
Z`( day of J�— 2021 1]G:V:A— .) Ly ,S1'r1` personally aPl>cored
before me,who is known to be the signer of the above instrument and acknowledged thathe(she)(they)signed it
Given,under my hand and official seal the day and year last above
",�analpprxrx .
M1r
yt'Q� M PAYS '•,
gslox e�pS�',y Notary Public in ' �r he5teteofWa9hingtoq
NOTARY i My commission expires: I2 Z9 Z�
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