HomeMy WebLinkAboutWAT2025-00245 - WAT Application - 12/19/2025 WAT 2025-00245
415 N.6th Street
elt "41 e111101MASON COUNTY Shelton,WA 98584
'SiOMMUNITY SERVICES Shelton:360-427-9670,Ext.400,,,,,,,,,,irr Belfair:360-275-4467,Ext.400
Building,Planning,Environmental Health,community Health Elma:360-482-5269,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 on Applicant: Timothy W. Jarrett Date: 11/24/2025
Mailing Address: 120 Ridge Dr., Port Townsend, WA 98368Phone: 360-662-6109
Parcel Number: 22212-75-90022
Type of Water System Reason for Application
I/ Public/Community Water System (2 or more V Building permit BLD2025-01344
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)
O 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.
Part 2: Water Connection Information EH APPROVED
Rhonda Thompson 12/19/2025
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Lakewood Heights
Water Facility Inventory(WFI) Number: 17999 L (write"none"for two-party)
VI am the manager of this water system. The water system has been approved for 74 services. There
are presently 66 connection(s) in use. This will be the 67 connection.
O 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 Brandy Milroy Phone 360-877-5249
Signature of Water System Manager ,., _,.,-4,,A lfl.r, ( t Date 07/18/2024
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 4/27/2021