HomeMy WebLinkAboutWAT2023-00340 - WAT Application - 5/18/2023 WATa -Q7
R E C E I V 415 N.6-6 Street
MASON COUNTY Shelton,WA 965a4
COMMUNITY SERVICE$NDy 2 S 2023 Shelton:360-427-9670,ExL 400
Be fair:360-275-W7.Ext.400
ls� Elms:360-482-5269.ExL 400
615 W. Alder street ENVIRONMENTAL
Application for Determination of Water Adequ"AEALTH
Instructions �1
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: Applicantl Parcel Identification
Name on Applicant: Matthew Knaaht Date: 0511812023
Mailing Address: PO Box 4 Wauna. WA 98395 Phone: 253-225-1542
Parcel Number: 123303390029
Type of Water System Reason for Application �/ Z
B7 Publit9Community Water System (2 or more IV Building permit.0tigz rJ �3Z�
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ 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 PubliclCommunity Water signature rgauYBdY']p O v E r)
System box. APPROVE .
r R
Part Z: Water Connection Information
DEC 22 2023
uaejj2N COUNTY ENVIRONMENTAL HEALTH
Complete the section appropriate for the type of water connection being eval RET
Public Water System
Name of water System: Cedar View Tracts Community Club
Water Facility Inventory(WFI)Number: 06151A (write"none"for two-parry)
Er I am the manager of this water system.The water system has been approved forte services.There
are presently 36 connection(s) in use.This will be the 36 connection.
❑ 1 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 Melissa Cox on behalf of NWS Phone 360-876-096e ae.to
Signature of Water System Manager- K ..r on behalf of NWS Date 05/18/2023
This form may be scanned and available for public view at www.co.maewn.wa.us.
1'dEn N.0 D. kin4 Water ReHmd a3712921