HomeMy WebLinkAboutWAT2023-00240 - WAT Application - 9/1/2023 I
WAT _
415 N.6'Skeet
MASON COUNTY Shdtm WA98584
Shelton:3670,Ez 400
COMMUNITY SERVICES
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Application for Determination of Water Adequacy
Instructio--
I. Complete Part 1. No determination can be made until Pan 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 accarnipmy this application-
Part 1: Applicant/ Parcel Identification
Name on Applicant: Earl x idn-A J. Date: 9W2,3
Mailing Address: '7SS 9(JWrPhone: Qo6) 3gl - 7502
km r Y
Parcel Number:
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more Le Building permit 8J b,--0,9L3— D/Ow
connections) ❑ Division of land:
❑ Individual we r source(one connection), #of Parcels? SPL
Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Omer(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 Public/Communify,Water signature required)
System box. `S __Cof� �tiOb
Part 2: Water Connection Information . r,`�
Complete the section appropriate for the type of water connection being evaluated. v"
I Public Water System
Name of Water System: rdj.;, $ i r��\
Water Facility inventory(WFI)Number JJr AtE
(write"none"for two-party) �1
l 1 am the manager of this water system.The water system has been appryyed for oG services.
There are presently 0 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 lliimitss set
/bby�state and local regulation.
Signature of Water System Manager _ Data
This form may be scanned and available for public view at www.co.mason.wa.us.
Revised VV2018
1:1EF1 Fmn Drinking Warn
1
Individual Water Well
1T Water well report(attached to application). Depth—LE) ft. 0
ttr'lWeli capacity Test(attached to application) 3 o gpm
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.
"tisfactory bacteriological test(attach to application).
Water Resource Inventory Area(MIA)
Development within which WRIA htto,/Iqis.co.mawn.wa.us/plannina 14_15k 16_22_
Water use a limitation recorded................................... MA :�k_Yes_
Well Drilled ............................................................... Date 21 20
Individual SpringlSurface 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 en the following observations.
Author of Statement Date
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
leason(s).
tisfactory Determination: guarantee an adequate supply of
is determination does not address adequacy of the distribution system,g as pP Y
ter indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
commended approval indicates requirements of sanitary Code,Tide 6,Chapter 6.68.a40-Determnation of
equacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
.70A RCW.
nsatisfactory Determination:
plicanfs water supply does not appear adequate to meet the needs of its intended oee for the following
Reviewer's Signatures:
Environ. Health: Date
This form may be scanned and available for public view at www co.mason•wa.us. vasr 2 of2
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Thurston County Environmental Health
2000 Lakeridge Dr.5W ♦Olympia,WA 98502
360 867-2631
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T� COLIFORMBACTERIAANALYSIS
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SAMPLE INFORMATION
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2201901 MASON CO WA
09,08,202, 02 53 PR NOTCE
1001NG6 Y190e26 Rec Fee' 8204 Be Pager. 2
ReturnTo
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Grardor(s):(+) Eel 5 zdalr^as .(2)
Grantee(s):(1)PUBLIC $98r"ro131 K3
cW SE
—v S
Legal Description(1) �yv � �
(Abbreviatedform:le.lot,block platorseclion,tm-stdp,range)
Assessoes Tax Parcel: M-3- z
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 cendi ions are based on location of property,and/or Water Resource
Inventory fta or WRIA.
WRIA:. tom--
Maximum Annual Average Gallons Per Day: r -(�I60 gallons
Dated on this 49 day of
Signature of Granntor(s):
(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�.2tt�
f�)7, -r d ,(� personally appeared before me,who is known to be
signer of the above ins ent,and acknowledged that he(she)(they)signed it.
GIVEN under my hand and official seal the day and year last above written.
I Er/111/"
.. r/
`��� � M2p'� Zy�, _ / o Publi n and for the�State of Washington,
zz ap7Agy.: _ residing at
c �•� N: _ My commission expires: n 7 tZ 3�2 CIZ
OP rWASN�p
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