HomeMy WebLinkAboutWAT Application - 10/12/2023 WAT
MASON COUNTY
COMMUNITY SERVICES
Bulldl,q.Pla,nl,g Envlronmenul Nialth Community Heald,
415 N 6-Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 0i Belfair.(360)275-4467 ext 400 4• Elms:(360)482-5269 ext 400
FAX(360)427-7787
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
Name on Applicant: Shelly Brander Date: p2� 3
Mailing Address: 545 6th Ave, Kalispell MT 59901 Phone: 406-671-6047
Parcel Number: 32010-50-01030
Type of Water System Reason for Application
0 Public/Community Water System (2 or more [a Building permit 20 2023 — b l ail(p
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 appplicable—nq
to this well, check the PublicYCommunity Water signature required) �W1y111t
System box.
NO NEW
Part2: Water Connection Information CONNECTIONS
Complete the section appropriate for the type of water connection being evaluated: PROPOSED
Public Water System
Name of Water System: Cedar Grove
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
❑ 1 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.
❑ 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.
Signature of Water System Manager n Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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