HomeMy WebLinkAboutWAT2022-00154 - WAT Application - 6/8/2022 ``�,hc:•
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WAT as- DD{541
ENVIRONMENTAL t_,
MASON COUNTY
HEALTH " ‘ ' COMMUNITY SERVICES
\�l ,`,e7g Building,Planning,Environmental Health,Community Health
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415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4• Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482qEe ICU � /
FAX(360)427-7787 "LIVED
Application for Determination of Water Adequacy Ali - 13 Aid
Instructions 615 W. Alder Street
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 Identi ication Name on Applicant: rif7h/ g�e ,,I#/ 40/ / -Date: /& —2/
,�Mailing Address: b 9Eclee . - , ne: 3 2- / ,/1e7 —92: f
Parcel Number: f 2 3 Z—ei' 3
Type of Water System Reason for Application
M r-Public/Community Water System (2 or more Mr—Building permit 7L0ao92-0073 ,
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water 0 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. ��
Part 2: Water Connection Information O VED
Complete the section appropriate for the type of water connection being evaluated: JUN 2 3 2022
4SON COUN
Public Water System TYVIV1R(Alit- lAL NFgLt
RET H
Name of Water System:
Water Facility Inventory(WFI) Number: 45-/tk .
(write"none"for two-party)
Cil I am the manager of this water system. The water system has been approved for.5;23 services.
There are presently `/�/ connection(s)in use.This will be the connection.
0 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 set b. and local regulation.
Signature of Water System Manager
Date w 7o 6 /202-/
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