HomeMy WebLinkAboutWAT2024-00170 - WAT Application - 3/25/2024 WAT
415 N.6's Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
1lelfid,360-2754467,Ext.400
MW 3ei1an%V1s up,rnmmwetl Hrdfl%G n11,t Elma: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 a lication.
Part 1: Applicant/ Parcel Identification r
Name on Applicant: VWP 5�,(e 1 Date: �/162T
Mailing Address: Gip � l `s ay? hone: ( $0471
Parcel Number: 226ZOMOD51
Type of Water System Reason for Application PubliclCommunity Water System (2 or more Building permit-TAC1202 +b04 i-I((��
connections) ❑ Division of land:
Individual water source(one connection), k of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface 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 PubliclCommunity 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-party)
I am the manager of this-water system.The water system has been P 1 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 stirte,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.
19EH Forms\Driaing Water Revised V412018
Individual Water Well
Water well report(attached to application). Depth�_tt.
Well capacity Test(attached to application) h 0 gpm �O V 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 rapacity test, which provides stabilization of draw-down and recovery data, must be performed
/by a licensed contractor.
Uy Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA
Development within which WRIA http,//ais.co.mason.wo.0 fanning 1+ 15_116_22_
Water use or limitation recorded................................... N/A Yes X .
Well Drilled ............................................................... Date—`�-LT_
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 on/
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:
Applicants water supply does not appear adequate to meal the needs of its intended use for the following
reason(s).
Reviewer's Signatures:Environ. Health: Date (Z�
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
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Lieeme No.2432 Ciy,SrR Zip TACOMA WA 99M18
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2209317 MASON CO WA
04/04/2024 10.54 an NOTCE
,AVID SA` illn 6374 196394-01 Rec rae: $304 6D Pages. 2
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Grantor(a):(1) Al 1n 5-rwa�s (2)
Grantee(s): (1) PUBLIC I
Legal Description (1) Lb f a3b`I ?4F %1174 Pyn(yLc+
(Ahlvavistedfirm:i.e.lot block platorsec6an, hxvnahip,range)
Assessor's Tax Parcel: (1)ar ?% L.2, - ) -_!IQQ a1
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 Masan 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:_ i'4
Maximum Annual A77verage Gallons Per Day: 95L gallons
Dated on this Aday of Y?I l ( .20 a`.
Signature of Gmrnor(s
(1) �7 ' - . (2)
State of Washington )
County of Mason )
Pagel of 2
I,the undersigned, a�ry Public in and for the above named County and State,do hereby
certify that an this _day of ffi�n) 202_ ,
�'AVl Gk FiFnl(P:� personalty 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.
eY P Patter '' Notary Public in And for the Slate of Washington,
VoJ�d•'F. a4j� ?�''•, residing at7YC'rY�P rSY�
c°i r1OTARY
My commission expires: 04' 21
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