HomeMy WebLinkAboutWAT2023-00023 - WAT Application - 11/3/2022 (2) - . WAT ZO 23 - 0O2,4)
• 415 N.6'h Street
' -`, MASON COUNTY - Shelton,WA 98584
Shelton:360 427-9670,Ext 400
COMMUNITY SERVICES Belfair.360-275 4467,Ext.400
y/ gui7dnq%arving.Environmental Hedth.Community Health
Elma:360-482-5269,Ext.400
•
Application for Determination of Water Adequacy
Instructions . . I
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 . .
Matt+Karen Eschbach Date: 11/3J2022
Name on Applicant:
Mailing Address: 12901 NE NorthShore Rd.Betfair,WA. 98528 Phone: 425-301-0846.-
Parcel Number: 322345000012 - ,
Type of Water System Reason for Application
ibl Public/Community Water System(2 or more tXI Building permit
connections) 0 Division of land:
0 Individual water source(one connection), #of Parcels'?i SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
El 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. APPROVED
► n p R O V
D
Part 2: Water Connection information !-�J—
Complete the section appropriate for the type of water connection being evaluated:
SON CO Ty
O 2023
Public Water System TY ENVI3 RONMENTAL HEALTH
REr
Name of Water System: Madrona Morningside Beach
Water Facility Inventory(WFI)Number: 50050 (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.
jsl( 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 fell time). Please indicate on the following line the nature of
this change: pew AD V W I w ni'or_AC r r TOT,1'1--st o c_ONN .GT ton.i S
This water system is able and willing to provide water to this(these)connections)without exceeding the
limits of the water system or any limits set by slate and local regulation.
Micah Olson Phone 206-681-3860
Print Name of Water System Manager— at-"--
l� ��
Signature of Water System Manager f/'- Date 1 /l
111
This form may be scanned and available for public view at www,Co.mason,wa.us.
' Revised 4i272021
J:\Eli Fonns\Drinking Water
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