HomeMy WebLinkAboutWAT2023-00322 - WAT Application - 11/13/2023 WATZO _s- OO ZZ
MASON COUNTY 415 N.66 Street
Shelton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfm 360-275-4467,En 400
Elma:360-482-5269,Ext.4W
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/�PAa,�rcel Identification
Name on Applicant: 1 V`G 111 - Ef 5 t D te: ( ��I2-3
Mailing Address: Q/Aely Phone: 360-4Zb-6Z�
r
Parcel Number: 62022-33-60000
J Type of Water System Reason for Application
la Public/Community Water System(2 or more Ii/J Building permit
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other❑ Other(explain) (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 NOV
' 3
1023
Complete the section appropriate for the type of water connection being evaluated:MASON COUNTYEREr NMENiAt HEALTH
Public Water System
Name of Water System: Mary M Knight School
Water Facility Inventory (WFI) Number: 42895 6 (write"none"for two-party)
❑ I am the manager of this water system. The water system has been approved for services. There
are presently connection(s)in use. This will be the connection.
F/ 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 time). Please indicate on the following line the nature of
this change: Active Connection
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 Brandy Milroy Phone 360-877-5249
Signature of Water System Manager l IA4 Date 10/27/2023
This form may be scanned and available for public view at www.co mason wa us.
rTH Forms\Drinl'ng Water Revised 4MQ011