HomeMy WebLinkAboutWAT2025-00229 - WAT Application - 12/15/2025 \VAT 2025 - OO229
MASON COUNTY 413 to ,W.6 98A94th rrrt
Shelton, 584
I!* Shelton:)60-427-c670,Ext.400
Public Health & Human Services Belrair: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: i 1t;'�; ls,ii t. >z s I r Date: _ ',i- 7
Mailing Address: 2916 NW BUCKLIN HILL RD 162 Phone: 360-649-7391
Parcel Number: 221232250020
Type of Water System Reason for Application
>] Public/Community Water System(2 or more )O Building permit BLD2025-01317
connections) 0 Division of land:
0 Individual water source(one connection), #of Parcels? SPL�
0 Well 0 Boundary line adjustment
D Springlsurface water 0 Other(explain)
O 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
Rhonda Thompson 12/15/2025
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: f\d,.o lA' tt
Water Facility Inventory(WFI)Number: ►s rC-Z,LI frk. (write"none"for two-party)
I am the manager of this water system.The water system has been approved for f services.There
are presently -'—t connection(s)in use.This will be the 5 connection.
U I are the manager of this system.This connection will he 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.
S0 G
Print Name of Water System Manager VL- 1 t�>� 1V I Phone.3L0O 1 r /�
Signature of Water System Manager ; .
- ---- ' Date 1` -1 )
This form may be scanned and available for public view at www.masoncountywa.gov
J:i1l Forms Unn:ing Itoistd 050.1024 °age I oft