HomeMy WebLinkAboutWAT2021-00287 - WAT Application - 1/20/2021 •P1.44 W AT 2 —50 R6,7
MASON COUNTY
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415 N 611'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: J & J Development LLC Date: 1/20/21
Mailing Address: PO Box 623 Burley, WA 98322 Phone: 253-208-8136
Parcel Number: 12220-50-60001 (Blk 60, Lot 1)
Type of Water System Reason for Application
RI Public/Community Water System (2 or more 0 Building permit
connections) 0 Division of land:
O Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ 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 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)
kJ I am the manager of this water system. The water system has been approved for 132 services.
There are presently 85 connection(s) in use. This will be the 86th 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.
Lawrence F. `h° g're°"`'"pp"``.`�
°��-` °``°°°°''°'"°"°' Date January 21, 2021
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Signature of Water System Manager Coppola -=`'�'My,o,,.Ea«u�,�.
Dec 2021 D121 1525,4S-09W
This form may be scanned and available for public view at www,co.main.wa.1/25/2.ugs.
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