HomeMy WebLinkAboutWAT2026-00022 - WAT Application - 2/26/2026 WAT 2026-00022
MASO CO 415 N.6`h Street
Shelton,WA 98584
a�,' Shelton:360-427-9670,Ext.400
•, Public Health & Human Services 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
Name of Applicant: 0 p y 7446. a.615<k Date: q.
Mailing Address: 7 d• n�t��sv a pl Phone: 36 a. 790.2-3 of e
Parcel Number: 321225000187 df 'Sc c.,„k' 51 »e"T'"
Type of Water System Reason for Application
Public/Community Water System (2 or more Building permit
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ 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. C3 3-187
Part 2: Water Connection Information EH APPROVED
Complete the section appropriate for the type of water connection being evaluated: Rhonda Thompson 02/23/2026
Public Water System
Name of Water System: 1.-,A L wWCr1 Lic Lic 4e r S.y ern
Water Facility Inventory(WFI) Number: t-(il)54 T- (write"none"for two-party)
p
I am the manager of this water system.The water system has been approved for t 3 +7services.There
are presently )2 81 connection(s) in use.This will be the I1gg 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 e.Jirj≤ 1' 01416 Phone 366 -sal-6258
Signature of Water System Manager @2.jL1t4i41t _ Date 7"30" 2o25'
This form may be scanned and available for public view at www.masoncountywa.gov
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