HomeMy WebLinkAboutWAT2026-00116 - WAT Application - 7/2/2026 WAT 2026-00116
415 N.6'h Street
MASON COUNTY Shelton,WA 98584
Shelton,360-427-9670,Bxt.400
°� Pu lIlc Health & an ervices Belfalr:360-275-4467,Bxt.400
Application.for Determination of Water Adequacy
Instructions
1 Complete Part I gip:determination,pan,be made until Part:I is full completed: '
2. ,:'. Complete only the portion of Part applying to the'(ype of water connection utilized,'
3: 'Submit completed.application with airy required att chm�nts for review..
4. :Ana rove .bulldin site.plan'must accoin an this.a Iication; .•:: :::: :' -:`
Part 1: Applicant/ Parcel Identification
Name of Applicant: A f►\v) K 6100— 1 Date:
Mailing Address: 4 & 7_ri 'L R0roAt�iFhone; 2p 1--p°•e;(
Parcel Number: 2.12--1— 7--C oo'37
Type of Water System Reason for Application
Public/Community Water System(2 or more -. Building permit BLD2026-00518
connections) ❑ Division of land:
O Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have more then 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 Y40 . c llcs rr,t' EH APPROVED
Rhonda Thompson 07/02/2026
Complete the section appropriate for the type of water connection being evaluated:
Public Water System.
Name of Water System:l�Gke (JA ≤h -
Water Facility Inventory(WFI)Number:•q'4i. __'r (write"none"far 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 ystem(i.e.: recreational to full time), Please indicate on the following line the nature of
this change: Boilo•fv\ti pQr4J4'°
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 1 ra l' e,94vdtt?r, Phone ;tO' l °" / 3
Signature of Water System Manager._ Q4UMAL Date 44-/S`Z 02(,
This form may be scanned and available for public view at www.masoncoun _ a.sov
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