HomeMy WebLinkAboutWAT2024-00167 - WAT Application - 3/13/2024 4 0
MASON COUNTY wAT
COMMUNITY DEVELOPMENT
permit ASAstaow Center,Bulltllog,planning
415 N 6"Street, Bldg 8, Shelton WA 98594,
Shelton:(360)427-9670 ext 400 Belfalc (360)275-4467 eat 400 ? Elma: (360)482-5269 sad 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 co 2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit com mpleted
pleted application,with any required attachments for review.
4. Ana roved building site an must accom an this a lication.
Part 1: Applicant/ Parcel Identification
Name on Applicant- S.,t�µ`go ty�{ Data
Mailing Address: O t3� 'Z—" Sli�ot,y Phone:
360 {z1 i INS
Parcel Number: 22_0 29 - 3`F -9 0 6 I
Type of Water System Reason for Application
Public/Community Water System (2 or more 1�
connections) T�-pwWlty EWI a Building permit 'BL_0aOot,4--OD�/a
❑ individual water source (dne connection), ❑ Division of land:
❑ Well #of Parcels SPL
❑ Spring/surface water ❑ Boundary line adjustment
Other(explain �rzr.� 0a e. ❑ Other(explain)
If you have more than one residence connected El Replacement or Remodel(please indicate name
to this well, check the Public/Community nee t e of water system below if applicable—no
System box. signature required)
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System �� E
Name of Water System:�ur1nlo.✓/`/ Oo_ y]_�-µ o j� 3(.rg�__��,���7�Z�j,�900�r�Water Facility Inventory(WFI)Nurriber: N o N rF
(write "none"for two-party)
f I am the manager of this water system. The water system has been appro for Z
r
There are presently t connection(s)in use. This will be theL services.
connecton.
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 intlicate on the following line the nature
of this change:
This water system is able and willing to provide water to this(these)ccnnection(s)without exceeding
the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Data J
This form may be scanned and available for public view at www co mason wa _
):TH For as\Drinking water
Ra-icN U^Sp01N
Individual Water Well WE opy-odo, Z
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test (attached to application) gpm 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 WRIA htlp Hgis_comason.waus/ tannin 7A[ 7515=16 d022=
Water use or limitation recorded._...._..._..................... N/AF_1p_Yesp�7 �1y8�
Well Drilled ..._............._............._.........._._............. Date !/L 1� loll
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 BOB 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)
XSatisfactory 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-DRtermination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirementsml4yfy'j1 . Chapter
36.70A RCW. a�s�y.
_. Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for th fpllowing
reason(s). G,1
Reviewer's Signatures
Environ. Health: Date
CSD Director: Date
2214855 MASON CO WA
t1om�—� 08/3313024 03.43 PA NOTGE
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Grantor(s): (1) ILh A J '^Z'V-Q— . (2)
Grantee(s): (1) PUBLIC ��"
Legal Description (1) Ln- 1 of S(°�-j94 K,1.%r 6 AF 142267L pTN of Nc- 00
(Abbreviated lone i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1)
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 and/or Water Resource
Inventory Area or WRIA.
WRIA: 14
Maximum Annual Average Gallons Per Day: gallons
Dated on this 2l day of %Ai� 2V4
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 that on this day of 20� ,
�Ua "vla_y 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.
auA N nuu
GoL �10 ], AO
Notary PublicA and fo a State of Washington,
NOTq S m.
residing at 521a IA) oPdQka
My commission expires:
"ur�WASNiNp"•
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