HomeMy WebLinkAboutWAT2024-00311 - WAT Application - 6/12/2024 seals
WAT �-003I I
MASON COUNTY 416N 6^Sako
Shelmo,WA 985M
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Public Health & Human Services Belfeir:36o-2)5-006),E.400
Application for Determination of Water Adequacy
Instructions
1. Complete Pan 1. No determination can be made until Pan 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 buildin site plan must accom ny this application.
Part 1: Applicant/ Parcel Identification
Name or Applicant: Empire Home Construction LLC Date: June 12 2024
Mailing Address: PO Box 241 Kelso,WA 98626 Phone: (360)751-8062
Parcel Number: 32021.56-02040
Type of Water System J Reason for Application
t( Public/Community Water System(2 or more y Buildingpermit BLDa0R,4-01N9
connections) ❑ Division of land.
❑ Individual water source(one connection), #of Parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Springlsunace water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
Oyou have more than one residence connected of water system below if applicable—no
to this we:f,check the PubAXommunify Water signature required)
System box.
Part 2: Water Connection Information ��
Complete the section appropriate for the type of water connection being evaluated. tp
n
Public Water System y
A
Name of water System: Shorecrest Estates Water Company 0i
Water Facility Inventory(WFO Number: 78620-1 (write"none"tor two-party)
d I am the manager of this water system.The water system has been approved for 00 services.There y P O
are presently 616 connections)in use.This will he the 617 cannectum.
❑ 1 am the manager of this system.This connection will be
).Please
upgrade or change the use of an the existing F
connection on this system(i.e.:recreational to full ems).Please indicate on Me fallowing line the nature of !
this change: y
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 stale and local regulation.
Pont Name of Water System Manager Moxi,Hutch, Phone (360)426-0773
Signature of Water System Manager Data June 12,2024
This form may be examined and available for public view at www.mas rnmuntvwa.aov
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