HomeMy WebLinkAboutWAT2024-00068 - WAT Application - 2/5/2024 " QOb(n�
MASON COUNTY wATaaa
IVIRONMENTAL COMMUNITY SERVICES
HEALTH WW%�rir,Emlranm "e C r4 Hmith
415 N 6ri Street,Bldg 8, Shelton WA 98584, � I V E D
Shelton:(360)427-9670 ext 400 d Belfair: (360)276-4467 ext 400 4e Elma:(360)482-52 e
FAX(360)427-7787
Application for Determination of Water Adequacy FEB -5 2024
Instructions i u VV Alder Street
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/ Parcel Identification
Name on Applicant: AB Fine Homes Dale:
Mailing Address: 871 E Beach Dr Union,WA 98692 Phone: 360-898-0055 opt 3
Parcel Number: 32104-52-00106
Type of Water System Reason for Application
* Public/Community Water System (2 or more El Building permit e>L90w ay- 60150
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 I applicable—no
to this well, check the PublicYCommunity Water signature required)
System box.
Part 2: Water Connection Information APPROVED
Complete the section appropriate for the type of water connection being evaluated: FEB 29 2024
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
Name of Water System: Alder6rook
Water Facility Inventory(WFI) Number: 01050 B
(write"none"for two-party)
❑ 1 am the manager of this water system. The water system has been approved for 636 services.
There are presently 5%t connection(s)in use. This will be the 533 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 (Le.: 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 andlocal regulation.
Signature of Water System Manager �41v "1`� Date 01/3112024
This form may be scanned and available for public view at www.co.mason.wa.us.
J.TH Forms\Dunking Water Revised 1,25/2018