HomeMy WebLinkAboutWAT2023-00213 - WAT Application - 7/21/2023 WAT aJ -3 - 002-I.S
U% 415 N.6th Street
MASON COUNTY Shelton,WA 98584
quip I = Shelton:360-427-9670,Ext.400
i. COMMUNITY SERVICES Belfair.360-275-4467,Ext.400
_.,--
Building PLimmng,Environmental Health Community Health Elm: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: Henley Wa 13, LLC Date: 07/21/2023
Mailing Address: 1537 NW Woodbine Way Seattle,WA 98177 Phone: (206)295-8589
Parcel Number: 32021-58-01006
Type of Water System Reason for Application
12( Public/Community Water System (2 or more Building permit 3L1)ao?'3 —cc
)151
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
O 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.
RPPROVED
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluate CEP 2 2023
'ASON COUNTYE;NViRONMENTAL 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)
15 I am the manager of this water system. The water system has been approved for 680 services. There
are presently 605 connection(s) in use. This will be the 606 connection.
0 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 Kristie Hutchinson Phone (360)426-0773
Signature of Water System Manager Date 07/21/2023
This form may be scanned and available for public view at www.co.mason.wa.u$.
J•'.1{li Forms,nrinkme eater Revised 4/27/2021