HomeMy WebLinkAboutWAT2023-00076 - WAT Application - 3/11/2023 WAT2 !Q -
fetri�l,i `} MASON COUNTY <E C E I V E ET
'ilvi i r - COMMUNITY SERVICES
k MAR 1 3 2023
��i` 'iv Building, Environmental Health,Community Health
2'it, i.�'tit w
415 N 6th Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 •:. Belf ext 400 •:• Elm:(360)482-5269 01,541 . Alder Street
FAX(360)427-7787
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: ,641I• p't O Date: ` .)28 Ile i,
Mailing Address: Q (SIoS bah Wek 1$YraPhone: '3lcf] "VS 3935
Parcel Number: l2'�S3C?• c'l •00610
Type of Water System Reason for Application �
Public/Community Water System (2 or more `14. Building permit-6I61 ZO2�'00� 19
`
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)
4 System box. ���� \O V
Part 2: Water Connection Information
MA
ED
Complete the section appropriate for the type of water connection being evaluated:
COUNPR 1 7 2023
Public Water System 1YENVIRONMEttiT�1 HEALTH
RET
Name of Water System: ,6Z7 K;,✓Y
Water Facility Inventory(WFI)Number: 06io0 E
(write"none"for two-party)
01- I am the manager of this water system.The water system has been ap ro d for .3 services.
There are presently 9,10 connection(*)In use.This will be the
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 b and local regulation.
Signature of Water System Manager
Date 403"UI-Z02
This form may be scanned and available for public view at www.co.masoevise`n�rw25a.curs.
JAM(Pones\Drinking Water