HomeMy WebLinkAboutWAT2023-00120 - WAT Application - 5/26/2023 wAIa0Z3- OoFj
isi.ws.,2 MASON COUNTY
ENVIRONMENT COMMUNITY DEVELOPMENT
HEALTH
Permit Assistance Center,Building,Planning
415 N 6"'Street, Bldg 8, Shelton WA 98584, �, r
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360)482t5269.ex1400`i L
FAX(360)427-7787
Application for Determination of Water Adequacy MAY 2 6 2023
Instructions 615 W. Alder Street
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: /e /lnd `j Date: 4/2-s �3
Mailing Address: �2f.J�� 4/itt /- Phone: � O 19d 937�
Parcel Number: kiai4e �� c7/e7of
ZZZ '>_7__- /9 0 0 1
Type of Water System Reason for Application
Public/Community Water System (2 or more Ouilding permit(J3 1 p3i0 pZ,3— 5.
9a
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ 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.
PROVED
Part 2: Water Connection Information SEP 4
Complete the section appropriate for the type of water connection being evall 2023
SIN COUNnEyyiRONMENTAI H
Public Water System �T HEALTH
Name of Water System: 1(11(
Water Facility Inventory(WFI) Number: '7( 20 (,l)
(write "none"for two-party)
t.1Y/I am the manager of this water system. The water system has been approved for 3/ (p services.
There are presently 251 connection(s) in use. This will be the 2(oc 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. l
Signature of Water System Manage �� Date 05/()`/2(�?3
1
This form may be scanned and available for public view at www.co.mason.wa.us.
I:`till Forms`.Drinking Water Revised 125/2018