HomeMy WebLinkAboutWAT2022-00082 - WAT Application - 3/30/2022 WAT?Oaa - U00$ d'L
-, MASON COUNTY
COMMUNITY SERVICES
, Building,Planning,Environmental Health,Community Health s ,y 4 "m y s
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 ~(DNMEN1RL
HEALTH
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: 'A1qv & Q \ i 1l-DDate:
Mailing Address:-.3O05 6 117'fk 6k. g Phone: a2✓3- 7 7- d /
Parcel Number: 42214-23-00130 -1-6.013
Type of Water System Reason for Application ��//��,,
� Public/Community Water System (2 or more I� Building permit ejL,Da02"d^JDytu1
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
El Spring/surface water ❑ Other (explain)
❑ Other(explain)
❑ 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 APPROVED
Complete the section appropriate for the type of water connection being evaluated: MAY 0 4 2022
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
RET
Name of Water System: Hoodsport
Water Facility Inventory (WFI) Number: 34100F
(write "none"for two-party)
M.' I am the manager of this water system. The water system has been approved for 326 services.
There are presently 217 connection(s) in use. This will be the 218 connection.
❑ 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 by state and local regulation.
Signature of Water System Manager '"" t,44 411,tacy Date 01/05/2022
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