HomeMy WebLinkAboutWAT2023-00049 - WAT Application - 3/1/2023 WAT �M 9
e -77:t.:.
• ..,:c.
MASON COUNTY
j M COMMUNITY SERVICES
%'y "' Building,Planning,Environmental Health,Community Health
415 N 61"Street, Bldg 8, Shelton WA 98584, � ���
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5 kt 0
FAX(360)427-7787
Application for Determination of Water Adequacy MAR - i 2O2a
Instructions 615 W. Alder Street
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. E PU ,/!R O N��E N TA L
4. An approved building site plan must accompany this application.
HEALTH
Part 1: Applicant/ Parcel Identification
Name on Applicant: Randell L & Leland M Henry Date: 8/29/22
Mailing Address: 61 NE WAGON WHEEL ROAD Phone: 919.505.1306
Parcel Number: 22202-54-02009
Type of Water System Reason for Application
0 Public/Community Water System (2 or more 0 Building permit ,1 Dg0a3—u/,g—
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ 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.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: WAGON WHEEL ESTATES
Water Facility Inventory (WFI) Number: #12080 F
(write"none"for two-party)
0 I am the manager of thi water system. The water system has been ap rove for 2 5 services.
There are presently connection(s) in use. This will be the • Yconnection.
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: Existing is adequate for new garage & suiti
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 nd to al regulation.
Signature of Water System Manager ' i�
Date 8/29/22
ig.7.-QA\ o- - --Ky-r, e-4- r-a/or--(Azu c&I---) .
This form may be scanned and available for public view at www.co.mason.wa.us.
1.\E11 Forms\Drinking Water Revised