HomeMy WebLinkAboutWAT2025-00220 - WAT Application - 11/17/2025 WAT 2025-00220
MASON COUNTY 415N.6"'Street
Shelton,WA 98584
Shelton:360-427-9670,Ext.400
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
Name of Applicant: t\i\PiVI e rti-o•ri LC Date: (4,-d()- ao 25
1 t o K st 6v,}t- $Y`41-64) 3 Phone: c ru Soi�>n��tJ
Mailing Address: C (oC -•`7S5 c —3 i�g0
Parcel Number: o2 Q� .r - S )--fl►O( I
lot 1`Tr" 1s EA-4.1 bk,
Type of Water System Reason for Application
N5 Public/Community Water System (2 or more Building permit
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
O Well 0 Boundary line adjustment
O 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.
EH APPROVED
Part 2: Water Connection Information
Rhonda Thompson 11;17,'2025
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: rat I / 1A.I9 1 �S�ri'c A
Water Facility Inventory(WFI) Number: /5 70 Ss fP (write"none"for two-party)
I am the manager of this water system. The water system has been approved for 313 services. There
are presently Z 5? connection(s) in use.This will be the 'sg 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 set by state and local regulation.
i
Print Name of Water System Manager c9E_/J'(dt2 2 lS Phone :3i;o sst Zc�3
i C /
Signature of Water System Manager a Date 6 -o10-t 0Z-�
tll ___ ���
This form may be scanned and available for public view at www.masoncountywa.gov
J:AEH Forms\Drinking Water Revtscd 05,08'2024 Page 1 of 2