HomeMy WebLinkAboutWAT2024-00301 - WAT Application - 7/19/2024 WAT _
413 N.61h Street
584
MASON COUNTY StiShelton,0,E t,400
COMMUNITY SERVICES Beltom 360-2754467,Ext.400
Belfair:360-275-0467,Ext.400
e�nn�s vnn,� sr„m,m maix�imco,m.�inx.,in, Elm.: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 roved buildin site Ian must accompany this application.
Part 1: Applicant/TParcel Identification
Name on Applicant: f W 11 rl w I f� Date:
Mailing Address: ZI ,J r S S. Q .?hone:
Parcel Number: 42219 sn_11003
Type of Water System Reason for Application
Public/Community Water System(2 or more Building permit C OIL 7i471—.5" �04�
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 wail, check the Public/Community Water signature required)
System box. APPROVED
Part 2: Water Connection Information AUG 09 2024
Complete the section appropriate for the type of water connection being evaluat%:SON COUNTY ENVIRONMENTAL HEALTH
Public Water System
Name of Water System: Hoodsoort
Water Facility Inventory (WFI) Number: 34100 F (write"none"for two-p7nnature
❑ 1 am the manager of this water system.The water system has been approved for_
J are presently connections)in use. This will be the connection.
qr 1 am the manager of this system.This connection will be to upgrade or change the use
connection on this system(i.e.: recreational to full time). Please indicate on the followin
this change: Active Connection
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 01/09/2023
This form may be scanned and available for public view at www co mason.wa.us.
R,,,s d4I27nWI
1:\EH Forms\Drinking Water