HomeMy WebLinkAboutWAT2025-00194 WATER ADEQUACY - WAT Application - 10/20/2025 WAT 2025-0.019
MASON COUNTY
COMMUNITY SERVICES
C. !(f4S4-tGv115 411 ri 60''0117s+-Cea Building,Fanning Environmental Health,Community Health
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5 N 6th Street, Bldg 8, Shelton WA 98584,
•:• Belfair: (360)42
36 �4687�400 Elma: (360)482-5269 ext 400
F
For Determination of Water Adequacy
ilination can be made until Part 1 is fully comp e
i.
if Part 2 applying to the type of water connection utilized.
on,with any required attachments for review.
Ian must accom an this a lication.
Part 1: App
{icant/ Parcel Identification' 1c <&,,r{A -KO VO.V n I()c lei rct 6 c,
Name on Applicant: l,l cc`,%cV woc ty-NA CA- '1 Date:
•
L ,n lh i=: 1 lCk,,,l hone: L�3 L � �,k:-
Mailing Address: 17�1� 1 fit? (��t 1/46 Pr ,���y ���1�
Parcel Number. .5'L11-1tii6t6 Ve �� ~�
- 53o Rd. a
Type of Water System
Reason for Application
l� Building permit
I Public/Community Water System (2 or more 0 Division of land:
connections)
❑ 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
of water system below if applicable-no
If you have more than one residence connected of nature squired}
to This well, check the Public/Community Water g
System box.
EH APPROVED
Part 2: Water Connection Information Rhonda Thompson 10/20/2025
Complete the section appropriate for the type of water connection being evaluated:
Public Water System`-
Name of Water System: Lc k - L iwter iL-K L 6A-eir Sy (-e m
Water Facility Inventory(WFI) Number: 9 11 515 1—
(write"none"for two-party)
iil I am the manager of this water system. The water system has been approved for 1 357 services.
There are presently I 2.84, connection(s) in use. This will be the 1217 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 li its sete by state and local regulation.
Signature of Water System Manager 14 MAL— Date -C.^2-6
This form may be scanned and available for public view at WWW& ,masoniw b1J