HomeMy WebLinkAboutWAT Application - 6/28/2023 WAT -
415 N.6`h Street
MASON COUNTY Shelton,WA 98584
Shelton:360-427-9670,Ext.400
COMMUNITY SERVICES Belfair.360-275-4467,Ext.400
Planning,Emmtmmenral Health,Community Health Elma:360-482-5269,Ext.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 / Q
Name on Applicant: NQr/A Rld fe frope-�J es �L Date: b 2 V 2O Z3
Mailing Address:P6 iboX 488 B eJ fa t r 98528 Phone: 36 d 731 7/6/
Parcel Number: /Z3 Z 8 " 2 3- 9Ob//
Type of Water System Reason for Application
Public/Community Water System(2 or more 0 Building permit
connections) )4/ Division of land:
❑ Individual water source(one connection), #of Parcels? 2 SPL Z 60-61)OIO17
❑ Well 0 Boundary line adjustment
O 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.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Be/FQi' Y�l����" /S7�"/C 47 '/
Water Facility Inventory(WFI)Number: 05 350 (write'none"for two-party)
ISt I am the manager of this water system.The water system has been approved for /05 services.There
are presently 7(,/ connection(s)in use.This will be the 7( .763connection.
❑ 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 by state and local regulation.
Print Name of Water System Manager _OakGIie.b Phone 340`27s'3
l
Signature of Water System Manager / �= Q << t/ 1 Date 7 $1,ZO�
This form may be scanned and available for public view at www.co.mason.wa,us.
1:'EH Forms'Drinking Water Rcvised4/27/2021
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