HomeMy WebLinkAboutWAT2023-00342 - WAT Application - 10/30/2023t
WAT .1,2- 003`tZ
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r1•+ 415 N.6th Street
MASON COUNTY Shelton,WA 98584
.I 1' F1; COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
f r/ Belfair:360-275-4467,Ext.400
2,, / Building,Planning,Environmental 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:,%=_�-/fc 4_1 sea L. r , o.f9 Date: /IA d 2 41
Mailing Address: 1/{,4: £. c-:1_l c_1- 4 F`.r., /'-c c, Phone: (/fin- J J-•53,
Parcel Number: /2//`js 3 oi,i,.ar' le,/4.,— �'4 c1&- •y
Type of Water System Reason for Application
Public/Community Water System (2 or more Building permit
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water 0 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 Ppc0
VET
Complete the section appropriate for the type of water connection being evalu?tied: NOV 3 0 2023
Public Water System ��++ S�N�vUNTYE4,,,,YIRO ,
J� m / f,, , (' �E;4TAL HEALTH
Name of Water System: a'r+fkir) C �'of(,� t �'1� er �J e w — (/`���
Water Facility Inventory (WFI) Number: 3/ 56 9 d (write "none" for two-party)
0 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.
m 1 am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on t is s tem (i.e,: recreation*to full time). P1 ase indicate on the following line the nature of
this change: (?i'.h j S h l / 9 (52.f C IOeir
This water system is able and will' 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 9 .4; Phone /7-27 2L//-i
Signature of Water System Manager Date /1/,3a/Z3
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Fonns\Drinking Water Revised 4/27/2021