HomeMy WebLinkAboutWAT2025-00225 - WAT Application - 12/10/2025 (2) W AT fQ `__ i a
S C410 U TV 415 N.6u`Street
Shelton.WA 98584
•
Shelton:360427-9670,Ext 400
Public an Services Belfarr: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:f'7=clif- 1/Mt 4#9/01 - 44-t.=a-,- Date: f� _
� ` l 6
Mailing Address:�,;,Wp ,�"M ~) dr 7 Phone: "
Parcel Number: 31097-50-00210 V2/Z) .S4-7 1n- r L4 ;'l
aZ
Type of Water System Reason for Application
Public/Community Water System(2 or more Building permit ". L} ' 6 o2
connections) O Division of land:
O Individual water source(one connection), #of Parcels? SPL
❑ Well O Boundary line adjustment
❑ Spring/surface water O Other(explain)
❑ Other(explain)
O 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 12/10/2025
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)
O 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_ . . j,, Date 11/04/2025
This form may be scanned and available for public view at www.masoncount wa.dov
.1,EFl Fonnsl Drinking Water Revised OS/0$/2024 Page 1 of 2