HomeMy WebLinkAboutWAT2023-00196 - WAT Application - 7/21/2023 , WAT gpa--3 - 00r61lg
415 N.6'F'Street
MASON COUNTY Shelton.WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Bclfain 360-275-4467,Ext.400
Building,Planning,Cnvircnmental Hatt,.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 16, LLC Date: 07/21/2023
Mailing Address: 1537 NW Woodbine Way Seattle,WA 98177 Phone: (206)295-8589
Parcel Number: 32021-56-03006
Type of Water System Reason for Application
VPublic/Community Water System (2 or more TI Building permit x aL 0 3-60acti
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) ( p )
0 Replacement or Remodel (please indicate name
If you have more than one residence connected of water sysAnIai if applicable—no
to this well, check the Public/Community Water signature r g ��7 Q O
System box. PRO CD
Part 2: Water Connection Information MASONOOU�EP 1 9 2023
Complete the section appropriate for the type of water connection being evaluated: ���NMENTA(HEALTH
Public Water System
Name of Water System: Shorecrest Estates Water Company
Water Facility Inventory(WFI) Number: 78620-1 (write "none"for two-party)
ti I am the manager of this water system. The water system has been approved for 680 services. There
are presently 606 connection(s) in use.This will be the 607 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:
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— r1l//t7, Date 07/21/2023
This form may be scanned and available for public view at www.co.mason.wa.us.
J::'EH Forms'.Drinking Water Revised 4;27,2021