HomeMy WebLinkAboutWAT Application - 8/16/2021 u4 WAT
MASON COUNTY
I. 1 COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
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: Red Door Design & Build L.L.C. Date: August 16, 2021
Mailing Address: 1706 Front Street.#443, Lynden,WA 98264Phone: 360-927-1578
Parcel Number: 122205064010
Type of Water System Reason for Application
l Public/Community Water System (2 or more kl Building permit
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 Spring/surface water ❑ Other ex
0 Other(explain) (explain)
)
0 Replacement or Remodel(please indicate name
11 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: Port of Allyn Water Company
Water Facility Inventory(WFI) Number: 68790X
(write"none"for two-party)
I am the manager of this water system.The water system has been approved 132 services.
for There are presently q9 connection(s) in use.This will be the 100th 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 e- o th' (t c ection(s)without exceeding
the limits of the water system or any limits s re ion.
Signature of Water System Manager Date August 16, 2021
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018