HomeMy WebLinkAboutWAT2025-00114 - WAT Application - 6/30/2025 . ` WAT ainp s - 00 /4 I
MASON COUNTY 415N.6`''Street
�4
Shelton,WA 98584
et- Shelton:360-427-9670,Ext.400
-11`"-�'t'= D' Public Health & Human Services Belfair:360-275-4467,Ext,400
Application for Determination of Water Adequacy
instructions II (D
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;conhectioh 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 Applicantv\' t,L('I - i}Ji-e.5 L-.Le , Date: 5 1 1 j �C —S_
Mailing Address•O.`30y_. .(.-{,ci� Phonc�t:,> �� i �'�-e
Parcel Number: �'2. ()I —7 • -- I • C`)o0-7 .
t 5(C) GO A. a.S;tp°z"� Reason for Application
Type of Water System J����8
Public/Community Water System(2 or more �/ Building permit �LNao
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Springtsurface 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. •
EH APPROVED
Part 2: Water Connection Information Rhonda Thompson 06/30/2025
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: 71,4LLIQ162 LQ beleeti"�}� `_"G '
Water Facility Inventory(WFI) Number: ge37o! (write"none"for two-party)
12 1 am the manager of this water system.The water system has l2een approved for/00 services.There
are presently 66 connection(s) in use.This will be the G 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 s t by state and lo 1 regulation.
Print Name of Water System Manager���V�l S "'n 7 Phone 36:o-y)7—��/"l}
Signature of Water System Manager --- 4. (// Date .e'e—IS.
This form may be scanned and available for public view at www.masoncountywa.gov
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