HomeMy WebLinkAboutWAT2025-00113 - WAT Application - 5/29/2025 WAT zo - ooi041 1?,
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MASON COUNTY
Shelton,WA 98584
"1` Public Health & Human Services s`'e
Belfair:36,�)p`'� 7 �EX`. 00
- 75- Ext.4
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: ilk I V-c- �jAvV )CAI \ Date: �j-I2j • 2
Mailing Address: Lc!O E r-APhone: 2o(;9 . �7S'� 20 22)
Parcel Number: 2-2-!Div - `13 j UU J
Type of Water System Reason for Application
14, Public/Community Water System (2 or more R Building permit
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
• 0 Well 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
❑ Other (explain)
❑ 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 06/3012025
9 Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Berl
Name of Water System: t e l jw :'1
Water Facility Inventory (WFI) Number: Ai _)9/v (write"none"for two-party)
0 I am the manager of this water system. The water system has been approved for services. There
are presently 3 connection(s) in use. This will be the L( 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. C�
Print Name of Water System Manager r—V4 t t'-'j Cn Vi Phone 3(.6() `J01 -y3 �5
Signature of Water System Manager Date I .3 Z'
This form may be scanned and available for public view at www.masoncountywa.gov
J:iEH Forms\Drinking Water Re.uc l Ir o8 2024 Page I „f'