HomeMy WebLinkAboutWAT2025-00116 - WAT Application - 6/3/2025 WAT ?OAS - 00//N/
MASON COUNTY 4on.WAhStreet
Shelton.WA 98584
Shelton:360-427-9670.Ext.400
le4
Public Health & Human Services Belfair:360-275-4467,Ext.400
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 �1
Name on Applicant: I'Q,Yy t &)/');fib.. Date: C���7/p�025
Mailing Address: So N� Sl4J Phone: 360-76 / d S99
Parcel Number: 3a I?2 5O Oo377
Type of Water System Reason for Application
X Public/Community Water System (2 or more jg Building permit 51JPDa6 -00(073
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL _
0 Well 0 Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) 0 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.
DOE. l3k.nhciw‘
Part 2: Water Connection Information O3-31Z APPROVED
Complete the section appropriate for the type of water connection being evaluated:
Public Water System JUL 0 3 2025
Name of Water System: L' I,,) -4 S S-�^e►+� MASON COUNTY ENVIRONMENTAL HEALTH
y �-.,�..Y.� t Alt-rick y RET
Water Facility Inventory (WFI) Number: t- -1I S6-r (write"none"for two-party)
XI am the manager of this water system. The water system has been approved for 13111 services.There
are presently 12.914 connection(s) in use. This will be the i295" 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 set by state and local regulation.
Print Name of Water System Manager eJr 04416 Phone 360- 5-67-6Z5B
Signature of Water System Manager i.- _ Date C"2-8—LO2-5—
This form may be scanned and available for public view at www.masoncountywa.gov
J:\EH Forms\Drinking Water Revised 05/08/2024 Page I of 2