HomeMy WebLinkAboutWAT2024-00134 - WAT Application - 3/11/2024 ENV!RONMENTAL
HEALTH WATo't0
RECEIVED 415 N.6'^Street
MASON COUNTY Shelm WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Et 400
MAR 11 2024 Belfaio 360-275.4467,Ext.400
a irar vr,nia,E . a,enu Haaa1% Elm.:360482-5269,Ext.400
615bv. , . _ t
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: Applicantl Parcel Identification
Name on Applicant:
Mailing Address: 1 t' PVe Phone: af)�
Parcel Number: 15.a.17- 1A -00(:!)F1
Type of Water System Reason for Application
❑ PubliclCommunity Water System(2 or more Building permh e)Loaoa4-ao3a
connections) ❑ Division of land:
Individual water source(one connection), #of Parcels? SPL
>C 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 it applicable—no
to this well, check the Public/Community 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)
❑ 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.masonma.us.
39En Fomu\Deinkine water Raiaed 4=021
Individual Water Well
Water well report(attached to application). Depth (0 1
tJ�VJell capacity Test(attached to application) `� gpm�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 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 Ififtfigis.co. ason.wa.us/plannina 14J 15_16-22_
Water use or limitation recorded................................... N/A_Yes_`r/ r ,
Well Drilled ............................................................... 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 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 Cade,Tide 6,Chapter 6.6e.040-Determinatlon 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: �
`�—) ��, 1MM,C llm Date
✓ -,I-
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 mf2
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Vanguard Laboratory
v 2635 Parkmont Lane SW,Suite A
Olympia WA 98502
0!!l1.4.1FD 360-%7-7010
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SAMPLE INFORMATON
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285- 10013
2217736 MASON CO WA
1013012024 11 05 AM NOTCr
MOHMBD PKPX KHANI $203093 AMC Fn $304 50 Page 2
Retum To
Mohamed Amax Khani 8 Loriann Khani
14211 90M Ave HE
Kirkland, WA 98034 .
Oo
Grantor(s): (1) Mohamad Amar Khani (2) Loriann Khani
Grantee(s): (1) PUBLIC
Legal Description (1) TR 7 OF GOVT LOT 2 , S 50/89 See 17,Town 22, Range 1
(A late rm:i.e. lot, flock plat orsaction, township, range)
Assessor's Tax Parcel: ( � 7 -1 4 - 0 0 0 7 0
TITLE NOT1PI WATER RESOURCE INVENTORY AREA (WRIA)
I (We),the undo ned g a), hereby place this notice on record that the described real
estate situated in son nty, State of Washington is subject to water use restrictions and
conditions on State Senate Bill 6091 and Mason County Code 6.68. These
restriction Ind o ns are based on location of property and/or Water Resource
Inver 0 rWR A.
ax ax m nual Average Gallons Par Day: 950 gallons
n this 25}h day of Or10ZE-k . 20 a.
nature of Grrardon(s/):/ �[
(1) 4 4 :✓c5 `2tti.�--- .(2)e/i. 7.! 'Q bLtil c�'YUC
State of Washington )
County of-Maaea i�ihA )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named unty and State, do hereby
certify that on this_��^day of_ � 20
p�(1nA IA K(1(fQj - WWII 1416VI1 personally appea , who is known to be
signer of the above instrument, and acknowledged that ) (they) signed it.
GIVEN under my hand and official seal the day and a love 'tten.
LNotary Public No Pu I ' I�n'd for the tste of Washington,
WasWagtoa din YIl'l—( MI
Ny BEARNESS1: XPIRESbsbn e)¢irea:26/2025
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Page 2 of 2
2217736 Page 2 of 2 10/30/2024 11:05:49 AM Mason County, WA