HomeMy WebLinkAboutWAT Application - 8/22/2022 WAT -
r4iy 415 N.6th Street,..•
MASON COUNTY Shelton,WA 98584
Shelton:360-427-9670,Ext.400
COMMUNITY SERVICES Bclfair:360-275-4467,Ext.400
BuilJiny,Planning,Environmental Health,Community Health Eltna: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: Joe & Kristie Berg Date: 08,22.2022
Mailing Address: 9831 Marine View Dr SW,Seattle,WA 98136 Phone: 206-724-2476
Parcel Number: 12105-52-00194
Type of Water System Reason for Application
g Public/Community Water System (2 or more SZi Building permit Oe1C -- _,q 1 K
DivisionCA/ k& b, r i' '
connections) ❑ of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ 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. RECEIVED
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
JAN 19 2023
Public Water System 615 W. Alder Street
Name of Water System: Treasure Island Country Club ( TICC)
Water Facility Inventory (WFI) Number: 891508 (write "none" for two-party)
Ld I am the manager of this water system. The water system has been approved for 255 services. There
are presently 229 connection(s) in use. This will be the 230 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.
Print Name of Water System Manag Savi Ly es Phone 360-876-0958
Signature of Water System Mana Date 08.22.2022
This form may be scanned and available for public view at www.co.mason.wa.us.
1:1H Forms Drinking Water Revised 4/27/2021