HomeMy WebLinkAboutWAT2026-00200 - WAT Application - 9/22/2026 WAT 2026-00200
MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6'h Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 . Belfair: (360)275-4467 ext 400 • Elma: (360)482-5269 ext 400
FAX(360)427-7787
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: Hauenstein LLC Date: 20221228
Mailing Address: 14781 Horseshoe Ave SW, Port (Phone: 317-697-7553
Parcel Number: 32232-52-08013
Type of Water System Reason for Application
El Public/Community Water System (2 or more D Building permit
connections) O Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well O Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) O 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.
EH APPROVED
Part 2: Water Connection Information Rhonda Thompson 09/22/2026
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: Ifni ut1
Water Facility Inventory (WFI) Number: 7 I g2fl,T )
(write"none"for two-party)
I am the manager of this water system. The water system has been approved for J r services.
There are presently 2 (ip, 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.: 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. u.�/66, 2z3
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018