HomeMy WebLinkAboutWAT2024-00306 - WAT Application - 3/27/2024 ENVIRONMENTAIc WATT - nn?iQ(�
HEALTH
ERECEIVED 415N.6 Street
MASON COUNTY Shel on,N.
6 98584
COMMUNITYSERVIC S Shelwn:360-427-9670.Ext.400
Bottom:360-275-4467,Ext.400
WMH%PNnni%F, mnmenul nzdm.mmmomryHe1A AUG 14 2024 Elmo:360-482-5269,Ext.400
der ,street
Application for DetermlihA '&WatserAdequacy
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: Empire Home Construction LLC Date: 3/27/2024
Mailing Address: PO Box 241 Kelso, WA 98626 Phone: (360) 751-1745
Parcel Number. 32021-58-04061
/ Type of Water System - / Reason for Application
K� PublictCommunhy Water System(2 or more 6r Building permitOL ` Qlx a
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water lain Other❑ ex
❑ Other(explain) (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 PubliclCommunity Water signature required)
System box. q r1 n ^o
Part 2: Water Connection Information y� 8EP 17
10VE®
Complete the section appropriate for the type of water connection being evai3N "iOUNTYENWRONM ENiAt HEALTH
Public Water System RET
Name of Water System: Shorecrest Estates Water Company
Water Facility Inventory(WFI)Number: 78620-1 (write"none"for two-party)
❑ I am the manager of this water system. The water system has been approved for services. There
are presently connection(s) in use.This will be the 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: Existing Connection-Building Permit
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 Kdstie Hutcl I son Phone (360)426-0773
Signature of Water System Manager Date April 9,2024
This form may be scanned and available for public view at www.co.mason.wa.us.
d:TH Forms\Drinking Water Revised 4=021