HomeMy WebLinkAboutWAT2023-00004 - WAT Application - 1/5/2023 s �
RECEIVED
i, N 0 5 773 WAT 26.2 - 00Y'6L-1
615 W. Alder Street
415 N.6`h Street
MASON COUNTY Shelton,WA 98584
g COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
�. Belfair:360-275-4467,Ext.400
Building Planning Environmental Health.Community Health Elm,: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: Amelia 1 LLC Date: August 8, 2022
Mailing Address:10036 Valmay Ave NW, Seattle,WA 98177 Phone: (206)295-8589
Parcel Number. 32021-58-04021
Type of Water System Reason for Application
X Public/Community Water System (2 or more X Building permit 3I6E 2o:2- _v0U r
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
❑ 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. n
Part 2: Water Connection Information 1A r PROVED
Complete the section appropriate for the type of water connection being evaluated: JAN 2 4
2023
Public Water System MASON CouNTy EhJJROMMENTAL WITH
Name of Water System: Shorecrest Estates Water Company RET
Water Facility Inventory(WFI)Number: 78620-1 (write"none"for two-party)
XI am the manager of this water system.The water system has been approved for 680 services.There
are presently 602 connection(s) in use. This will be the 603 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 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 Kristte Hutchinson Phone (360)426-0773
Signature of Water System Manager7(; :),‘Y � Date August 8, 2022
This form may be scanned and available for public view at www.co,mason,wa.us.
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