HomeMy WebLinkAboutWAT2024-00021 - WAT Application - 1/11/2024 WAT &24 - 000
MASON COUNTY Shchon,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ent.400
lldfnir:360-2754467,Ext.400
Elurdy,wm: 1-i— ,i a..e. Elm.:360-482-5269,Et.400
Application for Determination of Water Adequacy
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/ Parcel Identification
Name on Applicant: LXOd le.. A A b ii't Date:
Mailing Address: R ( ILP Phone: 701,2 -0O - 33Z5
Parcel Number: 22003-50-00007 :A44w— I,tA q&o-2-4
Type of Water System J Reason for Application
VaJ PubliclCommunily Water System(2 or more to Building permit '�0202 L4 - 0003 01
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ ReplacOther ement )
❑ 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.
Part2: Water Connection Information APPROVED
Complete the section appropriate for the type of water connection being evaluated: FEB U 8 2024
Public Water System MASON COUNTY ENV
Name of water system: Harstene Retreat
REi TI'
Water Facility Inventory(WFI)Number: 31572 M (write'none'for two-party)
V I am the manager of this water system. The water system has been approved for 48 services. There
are presently 32 connection(s)in use. This will be the 33 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.a.: 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 360877-5249
Signature of Water System Manager_L: W� Date 11/08/2023
This form may be scanned and available for public view at www.co.mason.wa,us.
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