HomeMy WebLinkAboutWAT2020-00117 - WAT Application - 6/27/2022 nEV)
WAT 202o - Poi i l•
1 MASON COUNTY
pi, COMMUNITY SERVICES
., sa ' BuddingPLmning,Environmental Health,CornmunityHealth
415 N 6in 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
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.
1 4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: J & J Development LLC Date: 1/18/2022
i Mailing Address: PO Box 137 Fox Island WA 98333Phone: 253-208-8136
Parcel Number. 12220-50-60008
101 E Sullivan Street
Type of Water System Reason for Application
ElPublic/Community Water System (2 or more 0 Building permit �j i d 2Q22.—00"188
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
1 ❑ Spring/surface water
❑ Other(explain) 0 Other(explain)
0 Replacement or Remodel(please indicate name
of water system below if applicable—no
If you have more than one residence connected
to this well, check the Public/Community Water signature required) _ ; 4, „,,,
System box.
Part 2: Water Connection Information JUN 2 7 2022
Complete the section appropriate for the type of water connection being evaluate S®N COUhn E;�'VIRON ENTA! HEALTH
Public Water System RET
Port of Allyn Water Company
Name of Water System:
Water Facility Inventory(WFI)Number: 60798X
(write"none"for two-party)
® I am the manager of this water system.The water system has been approved for 132 services.
There are presently 103 connection(s)in use.This will be the 104th 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 proved w r tot 's (th n ction(s)without exceeding
the limits of the water system or any lim's se st nd I on.
Signature of Water System Manager ( r-- r'� Date January 26,2022
This form may be scanned and available for ptlilic view at Www.co,mason.wa.us.
J:'EH Ions\Drinking Water / Revised 1 25,2018