HomeMy WebLinkAboutWAT2023-00307 - WAT Application - 10/24/2023 WAT tt)),01 - 00 D
415 N.6-Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Sheton:360427-%70,Eat 400
Belfair:360-275-4467,Ext 400
/ B0,ag PWEn.: —n .i x.114 c.n,nr.,mrrH..un EUna:360482-5269,Ft 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 accompanv this application.
Part 1: Applicantl Parcel Identification
Name on Applicant: Peter Jones& Lora Ann DuvallJones Date: 10.24.2023
Mailing Address: 26077Iverson Dr. South Riding VA Phone: iNh//yt . Zlb-r1511, 1J6'-1
Parcel Number: 22029-77-50030
_J Type of Water System Reason for Application
V Public/Community Water System(2 or more Building permit V1�01601�-V)JAgtf
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
ff you have more than one residence connected of water system below if applicable—no
to this well, check the PublicJCommunity Water signature requir�( 0dj..� O
System box. H
Part 2: Water Connection Information NOV 2 1 2023
Complete the section appropriate for the type of water connection being evaluat VSON COUNTY EWRON MENTAL HEALTH
Public Water System RET
Name of Water System: Jackson Timber
Water Facility Inventory(WFI)Number: 05192 T (write"none"for two-party)
❑ 1 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.
® 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: Inactive to Active Connection
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 Mill/roy yI /' Phone 360-8775249
Signature of Water System Manager� / � rj3� // Date 1 0/2 412 0 2 3
This form may be scanned and available for public view at www.co.masonma.us.
1:� Forms\Drinking Water Re ised4.'272021