HomeMy WebLinkAboutWAT2023-00221 - WAT Application - 5/2/2023 WAT 2-03 - 00.2-24
r 415 N.6ih Street
. MASON COUNTY Shelton,WA 98584
,- ' ' COMMUNITY SERVICES Shelton:3601327-9670,Ext.400
I ., Belfair 360-275-4467.Ext 400
BuJOing,Planning,E nvwonmental Health.Cammunity Health Elm:360-482-5269.Ext.400
ram.tuK .-
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: Henley WA 13 LLC Date: 05/02/2023
Mailing Address: 1537 NW Woodbine Way Seattle.WA 98177 Phone: (206)295-8589
Parcel Number: 32021-56-03021
Type of Water System Reason for Application
IX Public/Community Water System(2 or more X Building permit F WAW-j-00103
connections) 0 Division of land:
1..7 Individual water source(one connection), 4 of Parcels'? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water
0 Other(explain) 0 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. 4 P P R O V E D
Part 2: Water Connection Information SEP 2 0 2023
Complete the section appropriate for the type of water connection being evalp� ;�COUNTY ENVIRONMENTAL HEALTH
Public Water System RET
Name of Water System: Shorecrest Estates Water Company
Water Facility Inventory (WFI) Number: 78620-1 (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: Building Permit - Existing Meter 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 Kristie Hutchinson Phone (360)426-0773
Signature of Water System Manager 4 ? 5! Date 05/02/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
J:EH Forms\Dunking Water R -:
J