HomeMy WebLinkAboutWAT2024-00211 - WAT Application - 3/21/2024 MASON COUNTY I WAT
COMMUNITY SERVICES
&A&Y 1`6 . ewmmotle C�Halo
415 N P Street,Bldg 8,Shelton WA 98.584.
Shelton:(360)427-9670 ext 400 O Belfalr.(360)2754467 ext 400 O Elma:(360)482-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed
L2. 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 21an must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant &C-O j GO ftpr.) Date: 3 — L\
Mailing Address: 0%J rTw4poy rrAl, tiltphone: 34o —')] 1 ZLZ
Parcel Number: 61�t•fzM d— w.k g9rSyS H''l'n Dv e NpBLGS �.1)
37� LT2 — o — a 5 Type of Water System S \ O\o Reason for Ap rlicI p L
Public/Community Water System(2 or more X Building pem ft lbLDX Z4-006(0�
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ( xp )
❑ 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 PubliclCommunty Water signature required)
System box. APPROVED
Part 2: Water Connection Information JUN 0 6 2024
Complete the section appropriate for the"of water connection being evaluated: MASON COUNTY ENVIRONMENTAL HEALTH
Public Water System RET
Name of Water System: Hood Canal
Water Facility Inventory(WFI) Number. 340 10 M
(write"none"for two-party)
❑ 1 am the manager of this water system.The water system has been approved for 230 services.
131
There are presently 130 connections)in use.This will be the connection.
❑ 1 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:
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.
Signature of Water System Manager .n.,U,. ��i Date 03/21/2024
1
This form may be scanned and available for public view at www.co.masonma.us.
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