HomeMy WebLinkAboutWAT2023-00018 - WAT Application - 1/24/2023 ENVIRONMENTAL WAT ?,t-?LD - 600 le)
HEALTH
415 N.6'"Street
W MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair.360-275-4467,Ext.400
Building 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.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Cc-(Pm(,t,(, Date: I PA)123
Mailing Address: 3 9 J l+C wl A DC,Cj 1 Phone: , b 2 b - GaDcS�
Parcel Number: 51917-53-00037
Type of Water System Reason for Application
IS( Public/Community Water System(2 or more 0 Building permit
connections) 0 Division of land:
❑ Individual water source (one connection), � #of Parcels? SPL
❑ Well A 0 Boundary line adjustment
❑ Spring/surface water �9S A Ab ❑ Other(explain)
❑ Other(explain) O,r,
C 4J4� O❑ Replacement or Remodel (please indicate name
•If you have more than one residence conne s, /„.. of water system below if applicable—no
to this well, check the Public/Community Wate �y�0L9 ignature required)
System box. 7 C
Part 2: Water Connection Information �Fl ��q �L CE'VED
�y
Complete the section appropriate for the type of water connectioMfjing evaluated: JAN 2 �013
Public Water System 615 W. girler St.,E et
Name of Water System: Lake Arrowhead
Water Facility Inventory(WFI)Number: 43600 3 (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.
IV 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: Existing 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 Brandy Milroy Phone 360-877-5249
Signature of Water System Manager ''c , rti Date 01/24/2023
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