HomeMy WebLinkAboutWAT2025-00152 - WAT Application - 7/26/2025 .:may WAT 2025-00152
oCMASON COUNTY
., COMMUNITY SERVICES
I- ,e &idding,Planning,Environmental Health,Community Health
415 N 6'"Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 C. Belfair:(360)275-4467 ext 400 Elma: (360)482-5289 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: 'v l t d l t IrYI Date: 7 1-6'2-6
Mailing Address: c tc C 'e_ tr-t`-INYekhone: 2.s7-2- �J- ' 2
I NE.
Parcel Number: 1 -2.21 1U (v 5 A �-- y_- (v--T
P
Type of Water System Reason for Application
1B"Public/Community Water System (2 or more Er/Building permit
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 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 EH APPROVED
Complete the section appropriate for the type of water connection being evaluated: Rhonda Thompson 08/22/2025
Public,` �► Water,/ System! , ,
Name of Water System: M Q ket rd k 1C/L '� t,'.. 1 e 6.-tr, -
Water Facility Inventory(WFI) Number: �-1 SQC1C) 2-
(write"none"for two-party)
I am the manager of t�iis ter system. The water system has been p oyod forr7�services.
There are presently C•�I 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 pro . e ater to this (these)connection(s)without exceeding
the limits of the water system or any dlim* and local regulation.
Signature of Water System Manager z
-•—�_ Date ,,---`
__
This form may be scanned and available for public view at www.co.mason.wa.us.
J:1EH Fotms\Drinking Water Revised 1/25/2018