HomeMy WebLinkAboutWAT2025-00037 - WAT Application - 2/21/2025 WAT;/) - UDv)'q-
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MASON COUNTY
COMMUNITY DEVELOPMENT
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Permit Assistance Center,Building,Planning
415 N 6th Street, Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 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.
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: C/tea- �//77� Da �� Z/2O/ZD Z S
Mailing Address:`jy/ 6Sh //'/ c2 � Pc Phone: �ejD.S 9_3 37-S,S
Parcel Number: 3 2/Z 7- 5,2-/�" 2,2z
Type of Water System Reason for Application
® Public/Community Water System (2 or more ,$ Building permit---ept d 262 ,66A14
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
0 Spring/surface water ❑ Other(explain)
❑ Other(explain)
0 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 Co
nnection Information O`�P p ROVED
Complete the section appropriate for the type of water connection being evalu t : MAR 18 2025
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Public Water System ON COUNTY ENVIRONMENTAL HEALTH
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Name of Water System: I_c..ke mert(I ticeibi 5y5-ie"'n
Water Facility Inventory(WFI) Number: yell S'b
(write"none" for two-party)
Al I am the manager of this water system. The water system has been approved for 13T? services.
There are presently I 4' connection(s) in use.This will be the 1287. 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 () ) t'VfWa-- Date I-70205-'
This form may be scanned and available for public view at www.co.mason.wa.us.
1:\GH Fonns\Drinking Water Revised 1/25/2018