HomeMy WebLinkAboutWAT2021-00214 - WAT Application - 5/11/2021 — I WAT 202/ - 00Z4
MASON COUNTY FEILa
COMMUNITY SERVICES PIL4 i3td, PeMvit
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415 N 61h Street, Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 4 Belfair. (360)2754467 ext 400 O Elma:(360)482526 EI VE p
FAX(360)427-7787
Application for Determination of Water Adequacy MAY 11202,
Instructions 6f5 W. Alde t"ee
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: Ian Stenerson Date:
Mailing Address: 121 E Stonebriar PI Shefton,Wa 98584 Phone: 360-701-0188
Parcel Number: 32132-32-90112
Type of Water System Reason for Application
Rf Public/Community Water System (2 or more Building permit Adut 2021-oo O
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 Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Slonebriar 2
Water Facility Inventory(WFI)Number: 02783M
(write"none"for two-party)
❑ 1 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.
lif 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: active connection
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 arid-local regulation.
Signature of Water System Manager �-A 1 Date 05/07/2021
This form may be scanned and available for public view at www.co.mason.wa.us.
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