HomeMy WebLinkAboutWAT2024-00241 - WAT Application - 3/27/2024 WAT 24- 00 I
MASON COUNTY RECEGw,W 98594
COMMUNITY SERVICES Bet�1J6 4 55 E�4400
Made Pwm.s En✓.o,m w1i CarvnuniWl Ith Elma:360482-5269,Ext 400
615 W.Alder Street
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: Empire Home Construction LLC Date: 3/27/2024
Mailing Address: PO Box 241 Kelso, WA 98626 Phone: (360) 751-1745
Parcel Number: 32021-58-04059
/ Type of Water System Reason for Application
-0 Public/Community Water System(2 or more 6/Building permit
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 PubliclCommunity Water signature required)
system box. APPROVED
Part 2: Water Connection Information 1UN 2 ) 2024
Complete the section appropriate for the type of water connection being evaluated:MASON COUNTY ENVIRONMENTAL 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)
❑ lam the manager of this water system.The water system has been approved for services.There
are presently connections) 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 Pennit
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 Knstie HUP• i tson Phone (360)426-0773
J Signature of Water System Manager Date April 9,2024
1 This form may be scanned and available for public view at www.co.masonma.us.
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