HomeMy WebLinkAboutWAT2020-00163 - WAT Application - 1/9/2020 WAT_Z ) - doh
MASON COUNTY L
COMMUNITY SERVIC
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415 N 6th Street,Bldg 8,Shelton WA 88684.
Shelton:(360)427-9670 ext 400 4 Belfalr:(360)276-4a0T ext 400 + Elma:(380)482-5269 ext 400
FAX(300)427-7787
Application for Determination of Water Adequacy
instructions
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Part 1: Applicant/ Parcel Identification +�
Name on Applicant: P5ef t j._ Date: 1
Mailing Address: 224 11Iint ' �O
Parcel Number: ?1 O
Type of Water System Reason for Application
ity( PubliclCommunity Water System(2 or more t Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ S surface water In ----
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
Complete the section appropriate for the type of water connection being evaluated:
Public
�Water System
/1
Name of Water System: t�rrPeatl� Ifdi�.+`�► l&VIM
Water Facility Inventory{WFI)Number: 7O +�t r
(write"none for two-party)
6d.. I am the manager of this water system.The water system has been agprod for 0„services.
There are presently_5 to 1 connection(s)in use.This will be the D1 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 wiling to provide water to this( e)connections without exceeding
the limits of the water system or a limits set by state I ation.
Signature of Water System Manage ate
This form may be scanned and available for public view at Revised visLu ”
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