HomeMy WebLinkAboutWAT2023-00331 - WAT Application - 10/17/2023 WAT - �
415 N.6e St t
MASON COUNTY SheftM WA 99594
IQ) COMMUNITY SERVICES Shelma:360427-9670,Ext 400
Belfair.360-2754467,Ext 400
wasgvs.:nm.w x.+a.r�w,.�arNdn Elm&360462-5269,ESL 400
Application for Determination of Water Adequacy
Instructions
Y. 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 she plan must accompany this application.
Part 1: Applicant/Parcel Identification J
Name on Applicantli h4 OPc;GIrV+° Data: [O�[—(/
Mailing Address: Co CD Q
Parcel Number: /;,�33('�['('.'��i -g1 to- (oL41-( 1?Q T/✓)
Type of Water System Reason for Application
Y PublirJCommunity Water System(2ormom 14—Buildingpermit 51-WW-013919
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ 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 Public/Commumly Water signature required)
System box. AA
Part 2: Water Connection Information APPROVED
Complete the section appropriate for the type of water connection being evaluated: DEC 18 2023
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
Name of Water System: ew.-,
Water Facility Inventory(WFI)Number.
(write"none'for two-party)
❑ I 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.
Ja I am the manager of this system.This connection will be to upgrade or change the use at an existing
connection on this system (i.e., recreational to fNll time). Please indicate on the following line the nature
of this change: .e tJo/i e,�w.e-� �.i ,^4)
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 at and bcaI regulation.
Signature of Water System Manager Date 7-7V
This form may be scanned and available for public view at www.co.mason.wa.us.
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