HomeMy WebLinkAboutWAT2023-00102 - WAT Application - 2/28/2023 WAT�2 �'
rr MASON COUNTY
0111T17.1r ' COMMUNITY SERVICES CEIVED
Building,Planning.Environmental Health,Community He lh
415 N 6''Street,Bldg 8,Shelton WA 98584, u,Shelton:(360)427-9670 ext 400 " Belfair:(360)275-4467 ext 400 Elma:In 48235J. :: 400
FAX(360)427-7787 N V I R 0 N;M E N TA L
Application for Determination of Water Adequacy HEALTH
Instructions
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:UpyyeS•twig �tte:
t i ho ne: a 373S l a% `'1.b2 3
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Mailing Address: PO I�UX Sco v �� ho
Parcel Number: 111:3 ' c5 k- OV0 Zy
Type of Water System Reason for Application (�
)I Public/Community Water System(2 or more kf Building permit 6co �oa3_00 -t 9,
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. APPROVED
Part 2: Water Connection Information JUN 2 6 2023
Complete the section appropriate for the type of water connection being evaluated:
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
�� RET
Name of Water System: e.a1'Ff'u
Water Facility Inventory(WFI)Number: 4,5/'
(write"none"for two-party)
® I am the manager of this water system.The water system has been approved for 6.25 services.
There are presently 4 5c connection(s)in uso.This will be the t57 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 an Ii ' ate and local regulation.
Signature of Water System Manager
Date 03—J/'zpZ 3
This form may be scanned and available for public view at www•co,masoevisetnl�wa.us s
J:\EH Forms\Drinking Water