HomeMy WebLinkAboutWAT2025-00217 - WAT Application - 11/19/2025 WAT 2025-00217 I
MASON COUNTYtreet
Shelton,
8584
Shelton,WA 95584
nn Shelton:360-427-9670,Ext.400
Public Health & Human Services Belfair:360-275-4467,Ext.400
Application for Determination of Water Adequacy
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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: Mattson Land Consulting, LLC Date: 10.16.25
Mailing Address: 21227 88th Ave E Graham,WA 98338 Phone: 253-348-1200
Parcel Number: 32127-53-00196 0 LI-19‘
Z.6 0 6,6Ide L yme Rd.
Type of Water System Reason for Application
X Public/Community Water System (2 or more X Building permit BLD2025-01240
connections) 0 Division of land:
O Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
O 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
Rhonda Thompson 11/19/2025
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Lake- 1.-:mcfq,-k (,JGke,r S)/ -fir►,
Water Facility Inventory(WFI) Number: LiLi)$-6T' (write"none"for two-party)
I am the manager of this water system. The water system has been approved for 1311 services. There
are presently 1 NS connection(s)in use.This will be the /Z8 q 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.
Print Name of Water System Manager a
n 5 ('rf c l'IIer` Phone j�b 0�' ZS
Signature of Water System Manager Date 16-/5--2o2c
This form may be scanned and available for public view at www.masoncountywa.gov
J:1EH Fonns\Drinking Water Revised 05/08/2024 Page I of 2
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