HomeMy WebLinkAboutWAT2026-00131 - WAT Application - 7/22/2026 rtEcEVEr
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WAT 2026-00.131
MASON COUNTY415 N.6"Street
„* Shelton WA 98584
Shelton:360-427-9670,Ext.400
Pu lit Health & Human services Belfair:360-27S-4467,Ext.400
Application for Determination of Water Adequacy
Instructions
1, Complete Part 1. No determination can be made until Part I 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 accompanythis application,.
Part 1:'Applicant/Parcel Identification
Name of Applicant: /�.� ' jO, J2. Date: G/1?/
Mailing Address: /' b / O Phone;
Parcel Number:
/ ... � O4
Type of'Water System Reason for Application
cr Public/Community Water System(2 or more C( Bu.ilding permit
connections) 0 Division of land:
❑ individual water source(one connection)', #of Parcels? ' SPL
o Well ❑ Boundary line adjustment
o Spring/surface water ❑ Other(explain)
El Other(explain) ❑ 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 07/22/2026
Complete the'section appropriate for the type of water connection being evaluated:
Public Water System
Name bfWaterSystem:L4E JJ&h,0a•U %*$VA !!eh 446
Water Facility Inventory(WFI).Number: cYS 5O (write"none"for two-party)
1 am the'manager of this water system.The,water system has been approved for services.There
are'presently connection(S)in use:This will be the connection,
I'am the manager of this system.This connection will be to upgrade,or change the use of an existing
connection on,this system,(i.e.:recrtat'lonal to full time).Please indicate on the following line the nature of
this,change:-3;%bi^'t '"� • t'
'This water system.is able and willing to provide Water to this (these)conneetion(s)without exceeding the.
limits of the water system or any limits set by state and local regulation.
Print Name of Water System ManagerA YA°r 3�.S Phone Y&4$
Signature of Water System Manage Date, C.-ZZ-2
This form may be scanned and available for public view at www.masoncountywa.gov
J:1EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2