HomeMy WebLinkAboutWAT2023-00242 - WAT Application - 9/7/2023 WAT %4 -
415 N.6'Stint
MASON COUNTY Shelton,WA 99584
0 COMMUNITY SERVICES Shelton:30427-96/0,Ext 4W
9dfeir.360-27"61,Ext.400
aard`nvwarvr,.,amm.ery x..nnc«�n.gxryd, Elms:360492-5269,Fat 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 ��']3
Name on Applicant: Jason Campbell Futue Home Services Data: "I T 2-
Mailing Address: 406 108th ST S Tacoma WA 98444 Phone: 253-241-3594
Parcel Number. 12331-51-00054
Type of Water System Reason for Application
Public/Community Water System(2 or more M Building permit 50.707O/0b3
connections) ❑ Division of land:
❑ Individual water source(one connection), q of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ ReplacOther ement )
® Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below t applicable-no
to this well, check the Publ o Community Water signature required)
System box.
Part 2: Water Connection Information APPROVED
Complete the section appropriate for the type of water connection being evaluated: NOV 13 2023
Public Water System MASON COUNry ENVIROWENTAI wpiLiH
Name of Water System: ki RET
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
$ I am the manager of thi water system.The water system has been approved for 5Z3 services.
There; presently connection(s)in use.This will be the '15� 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 lime). Please indicate on the following line the nature
of this change:
This water system is able and willing to provide ter to this (these)connection(s)without exceeding
the limits of the water system or an se y s e and local regulation.
Signature of Water System Manager _ Date P9`1a716a1>
This form may be somned and available for public view at www.co.mason.wa.us.
3:\EE Farms\Dnnking Water Revised 4I4n018