HomeMy WebLinkAboutWAT2024-00095 - WAT Application - 2/26/2024 RECEIVED
FEB 2 6 2024 WAT
615 W. Alder Street
415 N.6e Street
MASON COUNTY Shelton,WA 99584
COMMUNITY SERVICES Shelton:360427-9670,EA 400
Belfair:360-275- 167,Exr.400
wrap,vr.myr,�bnm.,r.�x.nix.w,m„�xyx..ux Elms:360482-52 1400
Application for Determination of Water Adequacy
Instructions F416182024
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. F/VFD
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: e,'�' Date: d-
Mailing Address: Al 1 6 :P4 ^D r• Phone: 3ten R — 54.5
Parcel Number: 32104-56-00040
Type of Water System Reason for Application
!1
Mf PublictCommunity Water System (2 or more Ef Building permit ew-OR049/00 �N rJv,
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 Pubfia Community Wafer signature required)
System box. APPROVED
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated: MAR 15 2024
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
RET
Name of Water System: Alderbrook
Water Facility Inventory (WFI) Number: 01050 B (write"none"for two-party)
G( I am the manager of this water system.The water system has been approved for—Bar'—services.There
are presently 533 connection(s)in use.This will be the 534 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 360-877-5249
Signature of Water System Manager t.1f ,&,A' `1'�/ Date 02/26t2024
This form may be scanned and available for public view at www.co.mason.wams.
11EH Formal Drinking Water Revised 4n7n021