HomeMy WebLinkAboutWAT2023-00153 - WAT Application - 6/28/2023 RECEIVED
JUN 2 8 2023
615 W. Alder Street
WAT aoac- col 6
MASON COUNTY 4 o N.n,WAA 98584
f
6th Street
rw"IgieShelt o584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair.360-275-4467,Ext.400
Building,Planning.Environmental 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
Name on Applicant: Ken Hill Date: 6/26/23
Mailing Address: PO BOX 435 Allyn, WA 98524 Phone: (503) 888-6979
Parcel Number: 22127-51-00033
Type of Water System Reason for Application
[ ' Public/Community Water System (2 or more M' Building permit 4c12623 - Gb(- 2-
connections) ❑ Division of land:
0 Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
0 Spring/surface water
❑ Other(explain) ❑ Other(explain)
g Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below4 applicable—no
to this well, check the Public/Community Water signature required)
System box.
Part 2: Water Connection InformationJ ��M
Complete the section appropriate for the type of water connection being evaluated: QsoNeoUNr�N 30 202
3
Public Water System R�RCN4f 4f
Name of Water System:
RUSTLEWOOD .ZIf,
Water Facility Inventory(WFI) Number: 75027N (write"none"for two-party)
❑ 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.
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: Residential remodel. no other 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 Richard 1 n Phone (360)427-9670 ext.652
C _ _
Signature of Water System Manager<;7 -- - Date 6/27/23
This form may be scanned and available for public view at www.co.mason.wa,us.
1.1EH Forms\Drinking Water Revised 4/27/2021