HomeMy WebLinkAboutWAT2023-00251 - WAT Application - 9/20/2023 J �
WAT�oa3 ooa51
415 N.6h Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360427-9670,Ext.400
Beffeir:360-2754467,Ext.400
e„am,.y P� yt...........m[Ho tkC ,WH ih Elma:360482-5269,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/nParcel
Identification
Name on Applicant: S J)e+ y J)I&JJn6_ CC 1<2 Date: �-�•
Mailing Address: 1-0146 �5QG..G )4VE A) /
E Phone: " 25- `4A4H - 0333
Parcel Number: 32104-59-00015 5uax,-,(. - Aubuer— LAJA ge0j�
Type of Water System Reason for Application
Public/Communhy Water System(2 or more nl Building permit 3142OZ3- 0113 1
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 required)
System box. APPROVED
Part 2: Water Connection Information 18
Complete the section appropriate for the type of water connection being e�kg¢d, OCT 1 B NM23
Public Water System COUNIYENVRONMENiALHEALiN
44
Name of Water System: Alderbrook
Water Facility Inventory(WFI)Number: 01050 B (write"none'for two-party)
l/I am the manager of this water system.The water system has been approved for 636 services. There
are presently 529 connections) in use.This will be the 530 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 stale and local regulation.
Print Name of Water System Manager Brandy Milroy Phone (350)877-5249
Signature of Water System Manager Data 09/08r2023
This form may be scanned and available for public view at www.co.mason.wa.us.
11Ex Font Drhdc We@r xeviud 4/27/2021