HomeMy WebLinkAboutWAT2023-00129 - WAT Application - 6/21/2023 i
WAT Z•OL3 - olZ(1
415 N.6.Street
MASON COUNTY Shelton.WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
may Bellow:360-275-4467,Ext.400
Y�4y�-`'r9 sx.�yrw�..c r.,.o...,..utn«nnt rKwm Elm 360-482-5269.Ear.400
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:gQ)/fir 1 5 .1 r rJ 1 Z Date: 6/ /2 ,23
Mailing Address: 1) F, i, .IRKS nQ, 'S. Phone: 3(0-'2 /5 4.6
Parcel Number: I I 7^S'O'- UC ) (o t;
Type of Water System Reason for Application
g Public/Community Water System(2 or more 4 Building permit
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)
❑ Replacement or Remodel(please indicate name
tf you have more than one residence connected of water system below if applicable-no
to this well,check the PublicrCommuniry 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
p
Name of Water System: ���V�a-.//\ ‘` (Neese,/
Water Facility Inventory(WFI)Number..il-..x_ D/L- (write"none'for two-party)
4 I am the mans of this water system.The water system hasee,ry approved for l t services.There
are presently�ri(-( connection(s)in use.This will be the t'1I`f' 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 any limit r 'tte and 2� n ,
/17Print Name of Water System Manager / JI S r 1 Phone/U it 6,27s. '79
Signature of Water System Manager F , � �f Y' Date(pi
This form may be scanned and available for public view at www•co.masonll wa.us.
j'El4 Form\Drinking Wain Reri<ed.r•272021
APPROVED
JUN 2 1 2023
MASON COUNTY ENVIRONMENTAL HEALTH
RET