HomeMy WebLinkAboutWAT2024-00346 - WAT Application - 11/12/2024 WAT -QQ (�
MASON COUNTY
COMMUNITY DEVELOPMENT
Perme Aa;1$0me0e",BUIIEiry,Phnnbq
415 N 60 Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4 Belfair:(360)2754467 ext 400 4• Elmo:(360)482-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination ran 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. Wolf Industries/Jahnee Dragon Date: 9/202024
Mailing Address: 607 SE Eaton Blvd.Baffle Ground,WA 98W Phone: 360-912-9507 �n
Parcel Numinf: 321225000037 QS-( % 1-50 W*�Tb_neram.-xI ++�7 nv
Type of Water System Reason for Application
t0J PubIWCommunity Water System (2 or more N( Building permit JLDeZLR4 - D 1 a-t 0
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels9 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 PublicXommunify Wafer signature requiredL ROVE D
System box. H
Part 2: Water connection Information NOV 12 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: Lake Limerick Country Club
Water Facility Inventory(WFI) Number: `{'q 15 oT
.,,,.rr (write"none"for two-party)
yo I am the manager of this water system. The water system has been approved for l�l services.
There are presently IW I l connection(s)in use.This will be the IVI connection.
Id 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: NU (RN6SQ1J r`.Rlxl
This water system is able and willing to provide water to this (these)connection(s)without exceeding
the limits of the water system or an imit l
s set by state and local regulation. //;; � )
Signature of Water System Manager ^-'�_ Date I C)A -�.OZ'7
This form may be scanned and available for public view at www.co.masQn.wa.us,
1.EH Fomu\Dunking Water R,,,,d 1252018