HomeMy WebLinkAboutWAT2023-00229 - WAT Application - 9/14/2023 9/14/23, 10:05AM cid567C4B51-3DDC-4EA4-957B-6AFDD73D2BEF.jpeg
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.1117171F MASON COUNTY Shelton.WA Y 4 SSS
COMMUNITY SERVICES 1lxna>n.360-427a9670.aac.un)
helfair,360 27S-4467.E,it.400
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Application for Determination of Water Adequacy
Instructions SFp
1. Complete Part 1. No determination can be made until Part 1 fully completed
2. Complete only the portion of Part 2 applying to the type of water connection utilized 4 20
3. Submit completed application,with any required attachments for review. RFC�i�F ��
4. An approved building site plan must accompany this application.
Part 1: Applicant!Parcel Identification /
Name on Applicant: t 1 i,c ka cA ./c+�t v`Sr• Date: 7/ z. /:L; .3
:3`,i5tis .2^r14C<->�r
Mailing Address: ) it-q .7exr-, Phone. aC(c, 7 t j
Parcel Number: 32104-60-00103
Type of Water System Reason for Application
Pf Public/Community Water System(7 or more j$ Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection) ft of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
O Other{explain)
0 Replacement or Remodel(please indicate name
tf you trove more than or)t:residence connected of water system below if applicable—no
to this weft check the Public/Community Water signature required)
System box. / ,
Part 2: Water Connection Information �+ O V
Complete Inc section appropriate for the type of water connection being evaluated: MASON SEp 26 �0
Public Water System COONry�N�R ZO23
Name of Water System- Alderbrook RF7�NMENTA(ye,,
Water Facility Inventory(WFI)Number 01050 B (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.
•
Cd' I am the manager of this system.This connection wilt 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 tlx:nature of
this change Active Coanecslon____—_
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"6749
Signature of Water System Manager - Date 07/26/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
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