HomeMy WebLinkAboutUntitled (322) PGA\ WAT
/ MASON COUNTY IN
I COMMUNITY SERVIggIP° i� NTAL
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�yy "' / Building,Planning,Environmental Health,Community Health H LA LT H
415 N 6'h Street, Bldg 8, Shelton WA 98584, ;� �`�i 0
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 •: Elma: (36k4e .J�ktM00
FAX(360)427-7787 .
Application for Determination of Water Adequacu.c, 10 2022
P1der Street
Instructions �f�l•
1. Complete Part 1. No determination can be made until Part 1 is fully complete.
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: DAWN AND TRAVIS TWIDDY Date: 12/2/24
Mailing Address: 121 N. Enatai Ct., Skokomish, WA Phone: 360-490-1978
Parcel Number: 32006-50-02073
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit REMODEL/ ADDITION
connections) ❑ Division of land: (EXISTING SYSTEM)
Individual water source (one connection), #of Parcels? SPL
Well ❑ Boundary line adjustment
❑ pring/surface water ❑ Other (explain)
❑ Other (explain)
Replacement o 'emode (please indicate name
If you have more than one residence connected X of water system below I applicable— no
to this well, check the Public/Community Water signature required)
System box. Stu O 4 — D \�`-D
Part 2: Water Connection Information �/
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory (WFI) Number:
(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:
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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Fonns\Drinking W.at,nr Revised 1/25/2(1 IS