HomeMy WebLinkAboutWAT2023-00327 - WAT Application - 11/7/2023 ENVIRONMENTAL wAT 2 - Qn
HEALTH
415 N.6'^Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVI�KCEIVED Belton:360-275-4467,Ext.400
Belfair:360-275d467,Ex[.400
Buudn%mmm,g 8,.;r—nui H®nAeummu 'i H M Don:360482.5269,Ext.400
NOV 16 2023
Application for Deter"ggpA) ofr11fter Adequacy
et
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/ rParcel Identification
Name on Applicant: 'U -A04o- 1 y tkf�h Date: �I I� /Z#2 5
Mailing Address: Q0 V* 4-1N IW6 WrWA9 6-79 Phone: 360 - 3'0 -$001
Parcel Number: 32104-56-00065
Type of Water System Reason for Application II
S/ Public/Community Water System(2 or more Building permit 0L,/ R3 -C){'3/Q
6
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/Community Water signature required)
System box. APPROVED
Part 2: Water Connection Information DEC 18 2023
Complete the section appropriate for the type of water connection being evaluated: MASON COUNTY EWRONME6'TAL HEALT,
Public Water System RET
Name of Water System: Alderbrook
Water Facility Inventory (WFI) Number: 01050 B (write"none"for two-parry)
I/ I am the manager of this water system. The water system has been approved for 636 services. There
are presently 531 connection(s) in use. This will be the 532 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.
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 360-877-5249
Signature of Water System Manager f Date 1110712023
This form may be scanned and available for public view at www.co.mason.wa.0
JdEH FormA Dnnking Water Revised 4M7 021