HomeMy WebLinkAboutWAT Application - 8/2/2023 MASON COUNTY
COMMUNITY SERVICES e�a
BudMnq Pknnlig,EnWronmantal HeeXh Community HeelM
415 N 6'"Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 0i Belfair:(360)275-4467 ext 400 J Elms:(360)4825269 ext 400
FAX(360)427.7787
Application for Determination of Water Adequacy
Instructions *� (01'mo
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: Applicantl Parcel Identification
Name on Applicant: IMA45on UQIA !E11SU.t} LL& Date: '3 2 Zt3"L3
Mailing Address: 21227 88th Ave a Graham,WA 9833@Phone: �✓�3—J`0`d- (p207i
Parcel Number: ""I 00 Z 13
lxk_ye (_LrrelL2v o4 213 19t C: Uldfe LL nI Rd
Type of Water System Reason for Application
IDt PubliclCommunity,Water System (2 or more A Building permit 'F2)6l aoa3 - a 13&{
connections) ❑ Division of land:
❑ Individual water source (one connection). #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Ot lain)
❑ Other(explain)
eplaceme r Remodel(please indicate name
If you have more than one residence connected o water system below if applicable—no
to this well, check the Public/Community,Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Lox L_ LLIne i t CkS L,1atef'
Water Facility Inventory(WFI)Number: 4LI 150T
(write"none'for two-party)
R I am the manager of this water system.The water system has been a(Jproved fors N-7 services.
There are presently MP% connection(s)in use.This will be the I ZJA onnection.
❑ 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��lli"imits set by state and local regulation. W 1141 f558)
Signature of Water System Manager oh. z:J 11' O A-11dCL+ Date 'S - Z- ZO Z.1
This forme maybe scanned and available for public view at www.co.mason.wa.us.
J:EH 17 m Drinking W.W Revised 112WO18