HomeMy WebLinkAboutWAT2025-00228 - WAT Application - 12/15/2025 WAT 2025-00228
MASON COUNTY 415N.6thSheet
y, Shelton,WA 98584
I Public Health & Human Services Shelton:360-427-9670,Ext 400
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 ,iy•aArL` ci. ott' J it•-e+
Name of Applicant: c\C)•‘� Il v 1� ��u '.r\� r Date: i t /5 1 2-
Mailing Address:? S �� (� Phone: 3i Li `7 C((.) l ck3 if
Parcel Number: I 3�-i Z� -.5 I - (SUDS') O 2^ o -°
Type of Wear Sy te�m`o,ve" PL Reason for Application
Public/Community Water System (2 or more Building permit BLD2025-01 31 6
connections) ❑ Division of land:
0 Individual water source (one connection), #of Parcels? SPL_
❑ Well 0 Boundary line adjustment
❑ Spring/surface water
El (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.
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: L&(4 L:n.e-t,.c_4L.
Water Facility Inventory(WFI) Number: y y/5 O T. (write"none"for two-party)
I am the manager of this water system. The water system has been approved for I397services.There
are presently 12€ `1 connection(s)in use. This will be the /Z. J 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 (, 1 r;S f (C I I /1P \ Phone 360-`12 - ` 563
Signature of Water System Manager eJIJL1/LL Date i(- f 3.- Z°2S
This form may be scanned and available for public view at www.masoncountywa.gov
J:1E1-1 Forms\Drinking Water Revised 05/08/2024 Page of2