HomeMy WebLinkAboutWAT2025-00090 - WAT Application - 6/5/2025 •
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MASON COUNTY
COMMUNITY DEVELOPMENT
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• � permit Assistance Center,Building,Planning
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415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 { Belfair: (360)275-4467 ext 400 4 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: ✓`r.. G;• �c��,ji -. Date: 1 1<<__'_ �r
MailingAddress: K- Phone: ,S 3 _7 9`7 ?R(Q
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Parcel Number: � `?��'�' `
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Type of Water System Reason for Application
(El Public/Community Water System (2 or more 21' Building permit BOz�Q 5-00533
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL.
❑ Well 0 Boundary line adjustment
❑ Spring/surface water
El (explain) _ 0 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 signatureAlttjLed)
System box. /O—P R O V D
Part 2: Water Connection Information cI1��,, JUN 05
Complete the section appropriate for the type of water connection being evaairi 8OUN 2025
T' EV ONMEhT
Public Water System RET AL HEALTH
Name of Water System LSkz. L'Iv eriLR W G}C�r �y sIe
Water Facility Inventory (WFI) Number: Liy15-O rt
(write"none"for two-party)
J I am the manager of this water system. The water system has been approved for I 3q7 services
There are presently connection(s) in use. This will be the i 21' _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: AJFU1 CoNSTRLLT1olv_. �_•
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.
Signature of Water System Manager _.. -_. Date i-n-z4 z'$-- �
This form may be scanned and available for public view at www_co.mason.wa.us.
1:1EFI Fonns\Drinking Water Revised I/25/201R