HomeMy WebLinkAboutWAT2022-00086 - WAT Application - 6/28/2022 WAT ZV 2 - OOOP
{ MASON COUNTY
s5 COMMUNITY SERVICES
`„V Building,Planning,Environmental Health,Community Health
611
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 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Lake L(Vt1Qf(CL L 1t4 L +4 Whf -4 0- '5
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: -ae- eon cAtG.tk1On .1 t c._ Date: 3
Mailing Address: 71 t,'7- 54 4*Ave...G4"; MO, . Phone: 25$- (p$(a- (a tt
Parcel Number: 32 C22--50 -oo 20 1
Type of Water System Reason for Application
ti ublic/Community Water System (2 or more IR/Building permit 1i ion•oo44 -
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? I SPL
0 Well 0 Boundary line adjustment
0 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. ..��,,,, ww � n
Part 2: Water Connection Information 1�Q 11 t � 81L '4 ' 137116
28
Complete the section appropriate for the type of water connection being evaluated: Pn C
Public Water System
Name of Water System: Lc,rnerI� P R 0 V C D
� � JUN 2022
MASON COUNTY ENVIRONMENTAL HEALTH Water Facility Inventory(WFI) Number: LLB 1so
(write"none"for two-party) RET
oa.. I am tee manager of this water system.The water system has been appro ed for 15'1/services.
There are presently l25(p connection(s)in use.This will be the I�)fA connection.
I am the Jodtia or this system. This connection will be to upgrade or change the use of an existing
/ connection on this stem (i.e.: recre tional t9-`full time). Please indicate on the following line the nature
of this change: ULU (t ,Le sit- ..4e LM. 451r 1/061.114
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.�!
Signature of Water System Manager AZk_J d �'/7x J_9" Date34L-
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