HomeMy WebLinkAboutWAT2020-00013 - WAT Application - 1/12/2021 WAT ?,N D - Q6O2
MASON COUNTY
JJJ COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ext �/
FAX(360)427-7787
Application for Determination of Water Adequac '� J4A( 1 a ,
Instructions w aer
1
1. Complete Part 1. No determination can be made until Part 1 is fully completed. rOOt
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. E Iii
4. An approved building site plan must accompany this application. viRi NTAL
HEALTH
Part 1: Applicant/ Parcel Identification
Name on Applicant: Date: 1 112- '1._`
Mailing Address: \\ ,( JPhone: 3loo 3 - J _
Parcel Number: 22221-75-90022
Type of Water System Reason for Application
® Public/Community Water System (2 or more 0 Building permit
connections) El Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
0 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/Community Water signature required)
System box. APPROVED
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated: 7321
Public Water System ,jkS0NC0UNTYENVIR0NMENTRL HEEL`F
Name of Water System: Twanoh Heights
Water Facility Inventory (WFI) Number: 00153 Y
(write"none"for two-party)
® I am the manager of this water system. The water system has been approved for 75 services.
There are presently 46 connection(s) in use. This will be the 47 connection.
El 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 sett by state and local regulation.
Signature of Water System Manager ,1 r,a,, (-c_ 1 tc�4. Date 09/22/2020
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018