HomeMy WebLinkAboutWAT2023-00258 - WAT Application - 9/9/2023 •
WAT 20 2 - onae)
415 N.6th Street
• MASON COUNTY Shelton,WA 98584
i iii.ili V COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
i Belfair.360-2754467,Ext.400
&nldtng Plan...E nvrronmental Health Community Health Elma•360-482-5269,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! Parcel Identification
Name on Applicant: Hunter & Quincy Hohmann Date: 9/9/2023
Mailing Address: PO Box 1361 Allyn, WA, 98524 Phone: 360-801-0584
Parcel Number: 12321-21-94484
Type of Water System Reason for Application
Public/Community Water System (2 or more Building permit -01 d2A23 *6 i i V d%
connections) 0 Division of land:
0 Individual water source (one connection), #of Parcels? SPL
$ Well 0 Boundary line adjustment
0 Spring/surface water
0 Other(explain) 0 Other(explain)
0 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
R 4 pp
V�
Complete the section appropriate for the type of water connection being evaluated:, OCT 3 20 D
Public Water System COUhryEh�R�h�23
Name of Water System: �;0tkek LA/br -/-t-✓ 'ul S YL— Rer 647Ac HEA Tf r
Water Facility Inventory(WFI)Number: P\C- >,\y e
(write-none"for two-party)
I am the manager of this ater system. The water system has been appr ved for GI services.
There are presently connection(s)in use.This will be the 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 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. CI
Signature of Water System Manager ��/ 'I Date v' 2
This form may be scanned and available for public view at www.co.mason.wa.us.
J:Ell Forms Drinking Water Revised 4 4.2018