HomeMy WebLinkAboutWAT2023-00182 - WAT Application - 6/12/2023 WAT o-O2?j — Dojf3a-
I t
415 N.5th Street
MASON COUNTY Shelton,WA 98584
Irl '4r-l' COMMUNITY SERVICES Shelton:360427-9670.Ext.400
Belfair:360-275-4467,Ext.400
Buikling.Planning,Envlronmental 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: Baring Site Development Date: June 12, 2023
Mailing Address: 2913 4th Ave W Seattle,WA 98119 Phone: (509)8685691
Parcel Number: 32016-53-04005
Type of Water System Reason for Application X Public/Community Water System(2 or more )8( Building permit -W) 3-OO 5(8
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 Spring/surface water
❑ 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 rey(ylrpe()
System box. ��``11 ff'P ROVED
Part 2: Water Connection information qq SEP 19 2023
Complete the section appropriate for the type of water connection being evaluafeO.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)
E3 1 am the manager of this water system.The water system has been approved for 680 services.There
are presently connection(s) In use.This will be the connection.
XI 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: Existing Connection -Building Permit
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 (;0) i4:/.52.--
Date June 12, 2023
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 4/27/202I