HomeMy WebLinkAboutWAT Application - 3/19/2022 I
WAT
415 N.6n SUvet
MASON COUNTY Shelton,WA 98594
COMMUNITY SERVICES Shelton:360427-9670,Ext.400
Belfair:360-2754467,Ext.400
masyw.ny.[ a,..nirbxhca,.,..avrwn Elma:360492-5269,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 util .
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: Red Door Design & Build LLC Date: March 17,2022
Mailing Address: 1706 Front Street, Lynden,WA 98264 phone: 360-927-1578
Parcel Number: 122205054009
Type of Water System Reason for Application
® Public/Community Water System(2 or more ID Building permit BID2021-01509
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 well, check the PubfirlCommunity Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Port of Allyn Water Company
Water Facility Inventory(WFI)Number: 6879OX (write"none"for two-party)
® I am the manager of this water system. The water system has been approved for 132 services.There
are presently 100 connection(s)in use. This will be the 101st connection.
❑ lam 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)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 Lawrence F.Coppola Phone 360-275-2430
Lawrence F.
Signature of Water System Manager Date March 17,022
This form may be scanned and available for public view at www.co.mason.wa.us.
I:tEH FOmW Drinking Water Re,iud VM021