HomeMy WebLinkAboutWAT2023-00259 - WAT Application - 9/27/2023 WAT_?on- WAa'I-_
415 N.6'^Street
MASON COUNTY Shelton,WA 98584
�Nl�t COMMUNITY SERVICES Shelton:361W27-9670,Ext.400
B.Mdr:360-275-4467,Ext.400
Wfl*w wn',nrmi,mmeml HWWw munfte Elora:36"82-5269,En 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 7
Name on Applicant: K ro e1/t CNa Date:
Mailing Address: 2fq 23 T c+T
/1 . f A) t, Phatone:
Parcel Number. 32109-50-00065 -rnvez-
Type of Water System Reason for Application
Public/Community Water System (2 or more Ed Building permit 3514 2DZ3 e Oil Lf 3
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.
Part 2: Water Connection Information APPROVED
Complete the section appropriate for the type of water connection being evaluated: OCT 3 1 2023
Public Water System MASON COUN
Name of Water System: Alderbrook RET
Water Facility Inventory (WFI)Number. 01050 B (write"none"for two-party)
521' 1 am the manager of this water system. The water system has been approved for 636 services.There
are presently 515 connection(s)in use. This will be the 516 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 pmvide 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 1.j .n.,4) Date 07/21/2022
This form may be scanned and available for public view at www.co.mason.wa,us.
rTB F.v ,s lk k�W.W. Re cud a27R021