HomeMy WebLinkAboutBLD2026-00748 - BLD CD Environmental Health Review - 8/10/2026 (2) MASON COUNTY als srrCer
Shelton.0, t 419)
Public Health & Human Services l4el`a1"60'15-"'a.15-446?.Ex t. 0
Helton:air. 360-427-9670.Ext.400
WAT2026-00156
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 A licant: �zt1 _ -e
PP fir! r cL UYl It �?%. Date � i A, 2 .^ L
....-...
Mailing Address: 2 h ns Sr 4?,a �, ,.. dl..4 °7 rr•r Phone:
Parcel Number:
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more $ Building permitTi1e1 L62Ct.00 -16
connections) 0 Division of land:
❑ Individual water sogrce(one connection), #of Parcels? SPL
❑ Well O Boundary line adjustment
O Spdngisurface water
❑ Other(explain) ❑ 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.
v
Part 2: Water Connection Information Q �r�.� r,ti' ° ,]ti /' c>:L>
Complete the section appropriate for the type of water connection being evaluated: EH APPROVED
Public Water System Rhonda Thompson 08/1012025
Name of Water System: IS 'jr&.t 1J�`,},.1_r
Water Facility Inventory(WFI)Number: $`I O5's ra (write none"for two-party)
&l ¢Ltiv: moager.oCtpiwpfr crtsm-The.watecye4em-Nes beertappmved-er aivice$. There
are presently connection(s)in use. This will be the connection.
ai5 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 th following line the nature of
this change: A + a1 ...c 1") t'ca ,=a. . •,4 Is '�c. ,a,.-a7 �.a'�
This water system is able and wiling 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 1 Al"1. Phone - O •� =- �0`r'
Signature of Water System Manager _, Date . -L z-c
This form may be scanned and available for public view at www.masoncountvwa.gov
I-\EH Forms'Diking Water It i r4 , ^n:n rage I u2