HomeMy WebLinkAboutWAT2023-00002 - WAT Application - 12/7/2022 WAT 202 - 6D66)a
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e"p� �z 415 N.6th Street
MASON COUNTY Shelton,WA 98584
(5, ' 1 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
\'...•f. . Belfair:360-275-4467,Ext.400
�i , ,,..k' Build'ng,Planning,Environmental Health,Community Health Elma:360-482-5269,Ext.400
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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: fl`( I2f\/OCAbk. 1.A.1,y1q-A---xCUS� Date: \1•7.22-
Mailing Address: 260c G,\ARk 15 VN1anv svi.e\t0 hone:
Parcel Number: 22129-52-00007
Type of Water System Reason for Application
MI Public/Community Water System (2 or more )( Building permit . ie121'2 --OCc02-
connections) 0 Division of land: .R I )LL 2,0, 3 -O000
❑ Individual water source (one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 Spring/surface water
❑ Other(explain) 0 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 require
System box. APROVED
Part 2: Water Connection Information MAC! 17 2023
Complete the section appropriate for the type of water connection being evaluat4SON COUNTY ENVIRONMENTAL HEA`�TH
Public Water System RET
Name of Water System: Wonderland
Water Facility Inventory (WFI) Number: 98128 K (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.
12/ 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: Active 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 4.),ny q414,1,0 Date 12/06/2022
This form may be scanned and available for public view at www.co.mason.wa.us.
11EH Forms\Drinking Water Revised 4r27/2021