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Home My WebLink AboutWAT2023-00248 - WAT Application - 6/13/2023 , , � cNVIRONMENTAL , L...gac2z - b67q(c HEALTH WAT 2023 -Oo2`-c.8 JUL 1 3 2323 MASVSI <. 1VrStreet 5netwu, wr, 98584 (1111177 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: /'�I�. 41/0///i1 L. 6'/,861 Date: Mailing Address: y90 sE 414,),v6 .4-ve Phone: / 36o0 - 2.ez9- 334' Parcel Number: .3/9d'/ -53 - D40 99 00/OD Type of Water System Reason for Application Public/Community Water System (2 or more 0 Building permit connections) 0 Division of land: ❑ Individual water source (one connection), # of Parcels'? SPL 0 Well 0 Boundary line adjustment ❑ Spring/surface water lig Other(explain) 'leCEL COM 814)471M41 yz AMA. ❑ Other(explain) ® Replacement • -emodel .lease indicate name If you have more than one residence connected of water system be ow applicable- no to this well, check the Public/Community Water signature requir d) System box. C2\C.)0(\, Part 2: Water Connection Information ,V4`5 Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: �4-1.4)/U 2./. / iyiFfin/Tfti'4-A/6E_ co,,nr►i / SS/o,) Water Facility Inventory (WFI) Number: sZ y-7/3 (write "none" for two-party) am e water system ere are presently ilia 3 connection(s) in use. This will be the connection. Xf I am the manager of this system. This connection will be to upgrade or change the use of an existing connection on this sys�tem (i.e.: recr do al to full time). Please indi ate on the following line the nature of this change: (''o�tki-o i to//�jr^' "d- . �'& This water system is abletind 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 k///ty-, /�N/G Phone 3w0 - 4-5-1 Signature of Water System Manager //4. Date /k/-2-3 This form may be scanned and available for public view at www.co.mason.wa.us. 1:\EH Forms\Drinking Water Revised 4/27/2021 Caution: External Email Warning! This email has originated from outside of the Mason County Network. Do not click links or open attachments unless you recognize the sender, are expecting the email, and know the content is safe. If a link sends you to a website where you are asked to validate using your Account and Password, DO NOT DO SO! Instead, report the incident. Thank you Rhonda!! Sent from my iPhone On Mar 15, 2023,at 9:14 AM, Rhonda Thompson <RThompson@masoncountywa.gov>wrote: Ok great thank you. Mr. Seibert-please print off this email and include with your water adequacy form that you will submit for building permit. It is possible I won't be the one reviewing your application, so want to make sure anyone else will be able to figure out what we did here. Thanks, Rhonda Thompson, RS Environmental Health Specialist Mason County Public Health 415 N 6th St Shelton WA 98584 360-427-9670 ext. 581 Rthompson@masoncountywa.gov From: Tom Moore<tvmoore 171 @hotmail.com> Sent: Wednesday, March 15, 2023 8:56 AM To: Fawn Lake Office <fawnlakeoffice@gmail.com> Cc: Rhonda Thompson<RThompson@masoncountywa.gov> Subject: Re: Scanned image from Fawn Lake Caution: External Email Warning! This email has originated from outside of the Mason County Network. Do not click links or open attachments unless you recognize the sender, are expecting the email, and know the content is safe. If a link sends you to a website where you are asked to validate using your Account and Password, DO NOT DO SO! Instead, report the incident. Hi Rhonda My name is Tom Moore and I am the water system operator of record for the Fawn Lake Water System. Bill Knight is the trustee for the Fawn Lake Maintenance Commission and water system liaison. Bill is familiar with the operation and management of the water system and therefore has my authorization to sign Water Adequacy Determinations for the Fawn Lake Water System on my behalf. If you need anymore information regarding this matter please feel free to contact me. Tom Moore Fawn Lake Water System Manager A#xD; 360-426-9621 Sent from my iPad On Mar 14, 2023, at 1:34 PM, Fawn Lake Office <fawnlakeoffice@gmail.com> wrote: Tom, Attached is the front page of the Application for Determination of Adequacy signed by Bill Knight,Water Trustee for Fawn Lake. This is the one we discussed where he is combining the two lots for tax purposes and bringing to code. No new connection to the water system. Rhonda from Mason County needs your written approval for Bill Knight to sign on your behalf. Please reply all when responding. Thanks, Tom! Rhonda -when I get Tom's written approval back, I will contact Michael and have him come pick up the hard copy so he can bring to you with the rest of the paperwork. Thanks, Renee Olson Fawn Lake Maintenance Commission 471 Crescent Drive Shelton, WA 98584 360-426-1657 I www.fawnlakecommunity.com, Member Service Hours Monday, Wednesday & Friday Sam-lpm Tuesday & Thursday 3:30-6:30pm • Confidentiality Note:information contained in this email,including any attachments,is legally privileged and confidential information intended for the use of the individual or entity named above. lithe reader of this transmission is not the intended recipient,you arc hereby notified that any use,dissemination,distribution,or copy of this transmission is strictly prohibited. If you have received this transmission in error,please immediately notify us and destroy the original transmission. Thank you. Forwarded message From: Sharp Copier<fawnlakeoffice@gmail.com> Date: Mon, Mar 13, 2023 at 4:59 PM Subject: Scanned image from Fawn Lake To: < fawnlakeoffice@gmail.com> Reply to: Sharp Copier< fawnlakeoffice@gmail.com> Device Name: Fawn Lake Device Model: MX-4070N Location: Not Set File Format: PDF (Medium) Resolution: 300dpi x 300dpi Attached file is scanned image in PDF format. Use Acrobat(R)Reader(R) or Adobe(R)Reader(R) of Adobe Systems Incorporated to view the document. Adobe(R)Reader(R) can be downloaded from the following URL: Adobe, the Adobe logo,Acrobat, the Adobe PDF logo, and Reader are registered trademarks or trademarks of Adobe Systems Incorporated in the United States and other countries. http://www,adobe.com/