HomeMy WebLinkAboutCOM2025-00090 - COM CD Environmental Health Review - 10/21/2025 Cc-rr1a5• coo C,o
WAT -
1014, MASON COUNTY 5 41N.6mStroct
shett .6wA 98584
Shelton:360-427-9670,Ext 400
-- Public Health & Human Services Beifair:360-275-4467,Ext400
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.4Zauee Nee L la r 2. Date: /o/Z i/zOZS�
Mailing Address: /96 4Aff �ck nJ Phone: is 5-S$Z'5-40 ce
Parcel Number: /023,Z 4 - y/-90///
Type of Water System Reason for Application
Pubkc/Community Water System(2 or more ❑ Building permit
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
O Well ❑ Boundary line adjustment
O Spring/surface water 0 Other(explain)
❑ Other(explain) • 0 Replacement or Remodel(please indicate name
tf you have more than one residence connected of water system below if applicable-no
to this well,check the Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
rn Public Water System
Name of Water System: ?Al Act W (� 4,r. 4 1
Water Facility Inventory(WFI)Number: 0453SZ) (write'none"for two-party)
0 I am the manager of this water system.The water system has been approved for services.There
are presently connection(s)in use.This will be the connection.
Itg I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(I.e.:te�to full time).Please indicate on the following line the nature of
this change: t'.�j? it)
f
This water system is abl$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 Mana Phone 360'Z71"--300E
Signature of Water System Manager Date //-2Vad .
This form may be scanned and available for public view at www.masoncouritywa.gov
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