HomeMy WebLinkAboutWAT2023-00023 - WAT Application - 11/3/2022 - • _ WAT 2_0 23 - OObZ�
4r5 N.6th Street
' MASON COUNTY
- Shelton,WA 98584
` COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
�_ t pia �. , 3elfair.360.275-4467,Ext.400
!tutting.Plannnq tnvironm.ental Ileslth.Community Health t:lnw: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.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Matt+Karen Eschbach Date: 11/3/2022
Mailing Address: 12901 NE NorthShore Rd.Belfair,WA. 98528 Phone: 425-301-0846
•
Parcel Number: 322345000012 ,
Type of Water System Reason for Application
® Public/Community Water System(2 or more 52 Building permit
connections) 0 Division of land:
❑ Individual water source(one connection), #t of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ 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. A �P�O
Part 2: Water Connection information VE D
Complete the section appropriate for the type of water connection being evaluated: JAN 3 0 2023
Public Water System MASON COUNTY ENY1�pNMENjAL HE4bTh
Name of Water System:
Madrona Morningside Beach REF
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.
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: /VEw ,A.D\J (An Lt- nr`oT-.Aef T TTA-c--fit cc- �ONN�-T lCAJ S
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 Micah Olson Phone 206-681-3860
. I
Signature of Water System Manager ,77-'`'1' e2Zi.--"f"*-- Date 1 / 3 /1.--- —
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EIi Fonns\Drinking Water RCN s.d•1,27.2021
I