HomeMy WebLinkAboutWAT2025-00078 - WAT Application - 4/14/2025 WAT Zp?S - 00018
RECEIVED®6m Street
(1411MASON COUNTY QQ I on,WA98584
pnA SO=l iI ,670,Ext.400
-�..---= Public Health & Human Services Belfair:360-275-4467,Ext.400
615 W.Alder Street
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 of Applicant: KGLEP f s IA el-t LC, Date: LI -1 4 —Z5
Mailing Address: x L(21 Poi khone: 3t O.-LI S-SV I<
Parcel Number: •z2.2l2--SD - O?DD9 °(``3Lb ilo G' ELino( ?ear-- -41acL
Type of Water System Reason for Application
V Public/Community Water System (2 or more X Building permit
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 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 Connection Information 4 pPR
V"
Complete the section appropriate for the type of water connection being evaluated: hey n o 2025
Public Water System ASON OOUNTyE
RET bVEvTAL HEgLTh,
Name of Water System: ` �r WG-�'W ��s{�ZC-- ,
Water Facility Inventory (WFI) Number. 05 3SO (write"none"for two-party)
fgl I am the manager of this water system. The water system has been approved for tyo3 services. There
are presently c\t&eb connection(s) in use. This will be the Rtp connection.
0 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.
Print Name of Water System Manager \�. W b Phone 3in0 - 2-7S-3608
Signature of Water System Manager — i Date LI /11 iate-..S'-
This form may be scanned and available for public view at www.masoncountywa.gov
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