HomeMy WebLinkAboutWAT2024-00040 - WAT Application - 1/22/2024 ENVIRONMENTAL
HEALTH RECE °t `-CtM
MASON COUNTY JAN 22 2024 SBeio,WA9g as
COMMUNITY SERVI Shelton:360427-9670,Etl.400
— Alder Street Belfair.360-275-4467,Ext.400
wia.yw„ns,yrmironmexa xriavcammu,iryw.id, Elora:360-482-5269,Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part i 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: Date: 11aR
Mailing Address: Phone: ' o
Parcel Number: 22003-50-00008
Type of Water System Reason for Application
3aJ PubliG ;OL�liCommuniry Water System(2 or more '� Building permit 02G' 0J&6R_
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/Communify Water signature re wired
System box. XPbROVED
Part 2: Water Connection Information FEB 16 2024
Complete the section appropriate for the type of water connection being evaAtAE¢NI COUNTY ENVIRONMENTAL HEALTH
Public Water System RET
Name of Water System. Harstene Retreat
Water Facility Inventory(WFI)Number: 31572 M (write"none"for two-party)
IJ I am the manager of this water system. The water system has been approved for 48 services.There
are presently 33 connection(s)in use.This will be the 34 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.
Print Name of Water System Manager Brandy Milroy Phone 360-677-5249
Signature of Water System Manager hir< Date 11/0812023
This form may be scanned and available for public view at www.co.mason.wa.us.
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