HomeMy WebLinkAboutWAT2022-00121 - WAT Application - 6/30/2022 WAT 2 2 - 0012
415 N.6`h Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair:360-275-4467,Ext.400
&.ilting,Plannir,y.Enuonmental Health.Co+rrnunily Health Elm:360-482-5269,Ext.400
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: s-� ,-CS(,1r,, tom` , f( Date: M A-j l,o z_C
Mailing Address: tt-1`1C.A. C..rz)-(m\il e.44_ Phone: wit,-;i? .. t--JC1C,/
Parcel Number:
Type of Water System Reason for Application
jZt, Public/Community Water System(2 or more 'Building permit 1' V 2t22 •eatoot-(
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPt_
O Well ❑ Boundary line adjustment
❑ Spring/surface water - -
❑ Other(explain) p
Replacement • Remodel(please indicate name
If you have more than one residence connected • , - - -m below if applicable—no
to this well, check the Public/Community Water signature required)
System box. ,
Part 2: Water Connection Information APPROVED
Complete the section appropriate for the type of water connection being evaluated: JUN 3 0 2022
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
Name of Water System: '\ t C - t (\i -A--n,t' �' `
Water Facility Inventory(WFl) Number: a 6-35`00 (write"none"for two-party)
O I 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)iit 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: `-tt.:‘1 c,\�pr
This water system is able and wt ling 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 - ..fit? i3 6 Phone &et) r-z7S '30006
Signature of Water System Manager J _ / �; Date 10- /2Da .2-
i
This form may be scanned and available for public view at www.co.rnason.wa.us.
1 Ell Forms\drinking Water Revised 4/27/2021