HomeMy WebLinkAboutWAT2025-00224 - WAT Application - 11/4/2025 WAT - ->>;�,—1.
MASON
415 N. °'Street
Shelton.WA 98584
Shelton:360-427-9670,Ext.400
• Public Health & Human Services 13clfair: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 ) /J��_
Name of Applicant: t`/�CX•C�- //�A.J �/" Date: /ll/��` }—.40�
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Mailing Address:,jZ£ 1) 6+.iZ,1jk r 4L1-� � Phone: 9_7.3-vCJ 6 - 5,X t
Parcel Number: 31097-50-00240
Type of Water System Reason for Application
14/ Public/Community Water System(2 or more Si Building permit
connections) 0 Division of land:
0 Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
0 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.
EH APPROVED
Part 2: Water Connection Information Rhonda Thompson 1 2/1 0/202 5
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Madrona Park
Water Facility Inventory (WFI)Number. 0597933 (write"none"for two-party)
0 I am the manager of this water system. The water system has been approved for services. There
are presently connection(s) in use. This will be the 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: Inactive to Active Connection
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
Brandy Milroy Phone 360-877-5249
Signature of Water System Manager___
Date 11104/2025
This form may be scanned and available for public view at www.masoncountywa.gov
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