HomeMy WebLinkAboutWAT2022-00318 - WAT Application - 12/9/2022 WAT2°Zt - DO 51b
415 N.6th Street
(iilif1MASON COUNTY Shelton,WA 98584
'11' r 1 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair:360-2754467,Ext.400
Buiding,Planning Environmental Health,Community Health Elma: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. 1 i' j) Tl4-
(11 t ew_n.{-11� .
Part 1: Applicant/ Parcel Identification
Name on Applicant: t rU c Sr t (� PcJ L(1J U
Date: 1 2(c/c,-
r-
Mailing Address: (p S6 ((, = /�f Phone: 3— - it r31-0O
Parcel Number: a —q0j
Type of Water System Reason for Application
I 'Public/Community Water System (2 or more DV Building permit
connections) 0 Division of land:
O Individual water source(one connection), #of Parcels? SPL
O Well 0 Boundary line adjustment
O Spring/surface water 0 Other(explain)
O 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. /r•� PROVED
Part 2: Water Connection Information JAN 10 20223
Complete the section appropriate for the type of water connection being evaluated.
MASON COUNTY EN0RONMENTAI HEALTH
Public Water System RET
Name of Water System: Union
Water Facility Inventory (WFI) Number: 51920 W (write"none"for two-party)
0 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 connection.
VI 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: Active Connection
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.
Print Name of Water System Manager Brand Milroy _ Phone (360) 877-5249
Signature of Water System Manager` f( .> Date 01/09/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 4/27/2021