HomeMy WebLinkAboutWAT2024-00059 - WAT Application - 1/16/2024 RECEIVED
EWIRONNIENTAL WAT DOoS
JAN 31 2024 HEALTH
6 der Street 415 N.6-street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Eat 400
Belfair:360-275-4467.Eat 400
suron.wna.t ",.ti4x.ahh�mn.nMxwM 9atn.:36s-482.529,Bxt 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 rho 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: COSTELLO PACIFIC LLC Date: 1/16/2024
Mailing Address: LAKEWDODD a84D895W Phone: 1-253-2934943
Parcel Number. 12228-75-90032
�J Type of Water System Reason for Application
`f Public/Community Water System (2 or more 19( Building permit OLOaNN/1'001'5�—)
connections) ❑ Division of land:
❑ Individual water source(one connection), i)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: MAR 2 2 2024
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
Name of Water Systerri PEACOCK RIDGE
Water Facility Inventory Cli Number: 041727
(write none for two-party)
(7r I am the manager of this water system.The water system has been approved for 4 services.
There are presently 3 connection(s) In use.This will be the 4 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)connections)without exceeding
the limits of the water system or any limits set by state and local regulation
Signature of Water System Manager to T
This form may be scanned and available for public view at www cc.mason.wa.us.
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