HomeMy WebLinkAboutWAT2024-00020 - WAT Application - 1/11/2024 WAT i-4 -*ZO
415 N.6*Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:3W427-9670,Ext 400
Belfiik:360-275-4467,Ext.400
kd&%o Inq Emir—, HeelftC n., ,H-1i E1me:360-482-5269,Ext.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: v Date: I " II " 'Z 4
Mailing Address: 16& Phone'. ibU
Parcel Number: 22003-50-00009
Type of Water System J Reason for Application
V( Public/Community Water System(2 or more la Building permit '0jd202q - 668y
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
ff 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. APPROVED
Part 2: Water Connection Information FEB 0 8 2024
Complete the section appropriate for the type of water connection being evaluMWN COUNTY ENVIRONMENTAL HEALTH
Public Water System RET
Name of Water System. Harstene Retreat
Water Facility Inventory(WFI) Number: 31572 M (write°none"for two-party)
I/ 1 am the manager of this water system.The Water system has been approved for 48 services.There
are presently 34 connection(s)in use. This will be the 35 connection.
❑ 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)connections)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 Date 11/08/2023
This form may be scanned and available for public view at www.co.masonma.us.
1:1EH Forms\Drinking Water Revised VM021