HomeMy WebLinkAboutWAT Application - 3/13/2024 WATd�L
MASON COUNTY
COMMUNITY DEVELOPMENT
PttmIt Ani...oe..,6.4din&Pbnnil
415 N 61n Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 A Belfalr:(360)2754467 ext 400 A Elma:(360)482-5269 ext 400
FAX(360)427-7787
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 Pan 2 applying to the type of water connection utilized.
3. Submit completed application,with any required attachments for review.
4. An ariortived buildino site plan must accompany this application.
Part 1: Applicant! Parcel Identification
Name on Applicant: Bob Thompson Date: 3-13-24
Mailing Address: 250 N. Ayock Beach Dr., Lilliwa#hone: 360-269-7982
Parcel Number: 32303-50-01011
Type of Water System Reason for Application
ElPublic/Community Water System (2 or more El Building permit - J2D24-W3`{r-f
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑
❑ Other(explain)
Replacement o Remodel(please indicate name
If you have more than one residence connected r below if applicable—no
to this well, check the Public/Community Water signa ure required)
System box.
EXISTING CONNECTION
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of water system: Ayock Beach Improvement
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
❑ 1 am the manager of this water system. The water system has been approved for_services.
There are presently 56 connection(s)in use.This will be the 56 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.
Signature of Water System Manager Data 3-13-24
This form may be scanned and available for public view at www.co.mason.wa"us.
1:tEH Fon.\prinking Water Revised II15/018