HomeMy WebLinkAboutWAT2023-00337 - WAT Application - 11/20/2023 WAT ��
415 N.6°Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shdw.:360-427-9670,Eat.400
Belfair.360-2754M7,Ext 400
eau.yvw.ti9[mnnm.nx x..lu<cmmrinxwn Elma:360482-5269,ExL 4fM1
Application for Determination of Water Adequacy
Instructions I
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 Identiftca Ion T
Name on Applicant alA&W4 LI.L Date: aD
Mailing Address:10&�(e U4,(6uc!14 &CC��" `yPho ln�e5� aa¢ • ,FRS 'gS �j`�
Parcel Number: y 1 Jr' Z- nra e'�`ktJ q 1r t'1 —t
Type of Water System Reason for Application
Cf-Public/Community Water System(2 or more &'Buildingpermit BILD5109-3-0141B
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 Public/Community,Water signature required)
System box. APPROVED
Part 2: Water Connection Information DEC
2 0 2023
Complete the section appropriate for the type of water connection being evaluated: MASON COUNTY ENVIRONMENTAL HEALTI
Public Water System RET
Name of Water System: Timberlake Community Club, Inc.
Water Facility Inventory(WFI)Number. 88370Y (writs'none'fortwoparty)
_ ❑ lam the mane er of this water system.The water system has been approved for 1248 services.There
are presently�j connection(s)in use.This will be the 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)conneclion(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Marcus vnd 7,7 Phone (360)427-8928
Signature of Water System Manager Date a > --
This form may be scanned and available for public view at www.co.mason.wam
JBEH Forms\D tng walzr Revised 4'272021