HomeMy WebLinkAboutWAT2023-00050 - WAT Application - 3/2/2023 al
I WAT p2pa cw5O
MASON COUNTY
g. COMMUNITY SERVICES
=1
Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584, t.—�` A�"
❖
Shelton: (360)427-9670 ext 400 + Belfair: (360)275-4467 ext 400 Elma: (360)4 26u�Q„4 bt
FAX(360)427-7787
Application for Determination of Water Adequacy "i\R - 2 2:':.'2.
615 W. Atder Street
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 u itfi rV d i
C `RO NTAL
3. Submit completed application, with any required attachments for review.
4. An approved building site plan must accompany this application. HEALTH
Part 1: Applicant/ Parcel Identification
Name on Applicant: AB Fine Homes Date: 'g5/R4OR j
Mailing Address: 871 E Beach Dr Union, WA 98592 Phone: 360-898-0055 opt 3
Parcel Number: 32104-54-00067
Type of Water System Reason for Application
0 Public/Community Water System (2 or more 0 Building permit e,I.eo .9.zJ `oo(2ya
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 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. A Pp
'NO V
Part 2: Water Connection Information ��
MASQN APR 3 ?0
Complete the section appropriate for the type of water connection being evaluate a. CQQN 23
Ai
Public Water System EN�RQitnENTA�y
REr EA/TH
Name of Water System: Alderbrook
Water Facility Inventory(WFI) Number: 01050 B
(write"none"for two-party)
El I am the manager of this water system. The water system has been approved 636 services.
for There are presently 519 connection(s) in use. This will be the 520 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.
Signature of Water System Manager L-I(4); r 4'L' Date 03/01/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018