HomeMy WebLinkAboutWAT2024-00207 - WAT Application - 4/29/2024 WAT T- m2ol
415 N.6^Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shd=:360-427-9670,Ext.400
Be1f.k:360-2754467,ER 400
Elms:360492-5269,E#-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 1: Applicant/ Parcel I entification
Name on Applicant: ,/ / Date: S
Mailing Address: n.0 Phone: �d—:1 clif-4(
Parcel Number: 320zt-Af) -69 ol-z
-r Type of Water System Reason for Application
7D ,Public/Community Water System (2 or more Building permit t3�.02 Z.A OO'j�
( _ wnnectlons) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spnng/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 PublibCommunity,Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
p- /� Public Water System
Name of Water System: fn�l1k1' QA4C 4102
Water Facility Inventory(WFI)Number: AZnAC(write°none°for two-party) [0A!A-(nti P(4A&-L 2)2ozl •50(�10 `�,
❑ 1 am the manager of this wet r system.The water system has been approved for —Z.—services.
There are presently�connection(s)in use. This will be the Jwnnection.
❑ I 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 s state and Ioce1 regulation.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.masan.wa.r4s.
JV11 F. MnM,Water Revixd 4�42018
� //J� Individual Water Well
(}!✓Water well report(attached to application). Depth�_ft.
ll(❑nWell capacity Test(attached to application) 1,0 pm :7L400 gpd.
TThe well ddller 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.
gYSatisfaaory bacteriological lest(attach to application).
l Water Resource Inventory Area (WRIA)
Development within which WRIA hftp://gis.m.mason.wa us/olanniina 14_5_16_22_
Water use or limitation recorded................................... WA_Yea
Well Drilled ............................................................... Data��-3
Individual Springl8urface 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)
usfactory 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,Tille 6, Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36]0A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: 3// 1 Date 7 p CI f�l
This form may be scanned and available for public view atww%v.co.mason.wa.us.
Page2 or2
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2210166 MASON CO WA
-• 0412912024 09 31 AM NOTCE
BRRO F0 R pf W014 Fec Fee $304.50 Pages
IIIII I I 11 I!I III 01111 II I I ll III I I I I IIII!IIIIII I III IIIII Iilll 1111,1
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Grantor(s): (1) tT-)�r�[( zz,-. (2)
Grantee(s): (1) PUBLIC
Legal Description (1) Wpi.Nen. PAeK ADD P,Lra a rnrc 1-1-is S S4230
_
(Abbreviatedform:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 0_2�L- 5_0_- O 2QL2
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:I
Maximum Annual Average Gallons Per Day: Jy gallons
Dated on this 2-1_day of—7
Signature of Gra a {ay
(1) (2)
State of Washington )
County of Mason )
Page 1 of 2
I,the undersigned, a No Public anq r the above r gyed County and State, do hereby
ify t t on this Z • 'day of 20'�`yE
personally appeared before me,who is known to be
signer of the&1bove instrument, and acknowledged that he(she) (they) signed it.
GIVEN under my hand and official seal the day an yea st ab ve en.
\N X,XIIXI,M,
o�gER Sf�"„e
r .aJ sg\ON F�;P9 ss N ry Public linjand f r the of Washington,
°, .� pOTARV gyp;• i
23038426 - residing at
N+, pUBtIC My commission expires:
"•a,�WABNpoY
Page 2 of 2