HomeMy WebLinkAboutWAT2025-00154 - WAT Application - 9/22/2025 WAT 2025-00154
MASON COUNTY
COMMUNITY SERVICES
:,t-F4 Building,Planning,Environmental Health.Community Health
415 N 6th Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ 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.
14. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: 0J0 Cy (.k4( C 04-er Date:
Mailing Address: (Q(1 lf't� Q, 2(� `(f Phone: (AA -q
Parcel Number. "2.'�-'- Sc - oc'\--10 rrsceud
Type of Water System / Reason for Application
Public/Community Water System (2 or more iyI Building permit
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water ❑ 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.
Part 2: Water Connection Information
EH APPROVED
Complete the section appropriate for the type of water connection being evaluated: Rhonda Thompson 09/22/2025
Public WaterVC
System
Name of Water System: LQ ,�2L n a ( `�— rb\1 6.-1-eep
Water Facility Inventory(WFI) Number: 1-r/ Oc?C
(write"none"for two-party) (�
I am the manager of�t i wra-t�er system. The water system has been a roved for `I 1ervices_
There are presently -! ' connection(s) in use.This will be the 1'7—f 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 by state and local regulation.
Signature of Water System Manager Date 6" /2-26
Verified with Leanne at Lakeland Village that this is Richard Anderson signature
This form may be scanned and available for public view at
J:\EH Forms\Drinking Water Revised 1/25/2018