HomeMy WebLinkAboutWAT2023-00142 - WAT Application - 5/8/2023 RECEIVED
MAY - 8 2023 0 0 / 9a
615 W. Alder Street 415 N.6`t Street
MASON COUNTY r ? N Shelton,WA 98584
10117•:,.,,\
COMMUNITY SERVICES " ?ENTAtelton:360-427-9670,Ext.400
1I a L /t LTr� elfair:360-275-4467,Ext.400
Building,Planning,Environmental Health,Community Health 1 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: Timothy Goffrier Date: 04-30-2023
Mailing Address: 4337 15th Ave NE#814,Seattle,WA 98105 Phone: 206-992-3318
Parcel Number: 32106-75-90132
Type of Water System Reason for Application �� /�'�
Public/Community Water System(2 or more a Building permit Qj LQ o p-3-Cv7f v
connections) ❑ Division of land:
0 Individual water source(one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 Spring/surface water
❑ Other(explain) 0 Other(explain)
❑ 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 reAir
System box. r•J P R O� /E
D
Part 2: Water Connection Information JUN 2 6 2023
TH
Complete the section appropriate for the type of water connection being evaltat Qt COUNTY E!t`�1ROhMENTAI
Public Water System RET
Name of Water System: Union Ridge
Water Facility Inventory(WFI) Number: 06553 V _ (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.
Mi 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 t' ,�..,(; '���1 7 Date 05/01/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
JAE11 Forms\Drinking Water Revised 427,'2021