HomeMy WebLinkAboutWAT2024-00106 - WAT Application - 10/11/2024 MASON COUNTY I xr^1
COMMUNITY SERVICES WA 1 ZOZY �(j106
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416 N V Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext I00 P Belfair:(360)2754467 eA 400 4 Blma:(360)482-5269 ext 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 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
Name on Applicant: Ga \/1 o Cq s-`r- Date: '7-'Z8-24
Mailing Address: po 207r SQoo Phone: '56- 7ef 7,-993"4
Parcel Number. b33-y/- SWID
e
Type of Water System Reason for Application
Public/Community Water System (2 or more wilding permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL _
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have mom than one resfdence connected of water system below if appli ble-no
to this well, check the Publiccommunity Water signature required)
system box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated: 'pFC�2 101�
��// i Public Water
�S��ystem W&2021 P�
Name of Water System: / 4J ✓4 AW 141^' A OM--
WaterFacility Inventory(WFI) Number; Ytvhl=
(write"none"for two-party)
I am the manager of thi water system. The water system has been approved for I services, 'r
There are presently I 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 (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 thi"hes(e)connection(s)without exceeding
the limits of the water system any limits set by sw6la o I regulation.
Signature of Water System Manager ' Dale 6�k2y
This form may be scanned and available for public view at www.co.masan wa us.
Revised 1.25P(n8
I'WN Farman Drieking wailer
Individual Water Well
�A Water well report(attached to application). Depth ft. )
Well capacity Test(attached to application) I 3 opm ( O�aO gpd.
The well driller often performs well rapacity 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.
�I Satisfactory bacteriological test(attach to application). L( Z( r ZOZ j
Water Resource Inventory Area (WRIA)
Development within which WRIA http�ilgiscomason.wa.us/planning 1ArLP CAj5016fl220 Bs
Water use or limitation recorded................................... N/Ay�Yes,�*W-1z16uQ
WellDnlled ............................................................... Date
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 Data
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,Me 6,Chapter 6.66.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requiremeol papply. Chapter
36.70A RCW. A
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its Intended use for fbe foll
reason(s).
CO j O
/ Reviewer's Signatures: 19 EN 1y
Environ. Health: //U Date 't ROAM Thy
CSD Director: Date :ot:
bL1pao� o"50
2216482 MASON CO WA
ENVIRONMENTAL F.. Co2Nrr'P111 oM�N°bE11 N1129 Rec Fee $304 S° Paws 2
HEALTH IIIIIIIIIIIIJIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIVIIIIVED
OCT — 12024
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Gmntor(s):(1) w
Grantee(s):(1) PUBLIC �-
Legal Description (1) 5331120'�3
(Abbreviated form:i.e.lot, block,plat or section, township, range)
Assessor's Tax Parcel: ('I)3-.�-L Q-3-3---4-L.- 6- 4--L-A2-
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 andlor Water Resource
Inventory Area or WRIA.
WRIA:I- (1�r�
Maximum Annual Average Gallons Per Day:ESL—gallons
Dated on this day of Q Y' 201!1
Signature of Grantor(s):
(1) h� 0 Qo r-- (2)
State of Washington )
County of Mason )
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1,the undersigned, a Notary Public' nd for above named County and State,do hereby
grtify that on this �- day of 20
I 1 AAtJ personally appeared before me,who is known to be
signer of thelabove instrument and acknowledged that he(she)(they)signed it.
GIVEN under my hand and official seal the day and year last above writte
Notary Public in and for the State Washington,
=TIRESALWAY .blic residing atingtonr 135501My commission expires:
n Expires024
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