HomeMy WebLinkAboutWAT2022-00018 - WAT Application - 1/21/2022 is) ,"m. _ I w tk t "lo 2'L - 000 it
,i.\(P �ri)0 *- MASON COUNTY �I fs
' 2 i i._. COMMUNITY SERVICES A- I t} I
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P A e \' Building,Planning,Environmental Health,Community Health `C C. �t��}l�
t,, tl?,V, 415 N 6th Street, Bldg 8, Shelton WA 98584,
'� Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 •:• Elma: (360)482-5269 ext 400
.` ;�\s FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions ` �t(,t,; -i(!., . ( ,x i 1 1_ ,R. �_ i t 'ir> i ,, i" -,
1. Complete Part 1. No determination can be made until Part 1 is fully completed. ��
2. Complete only the portion of Part 2 applying to the type of water connection utilized. C /,V/E
3. Submit completed application,with any required attachments for review.
4. An approved building_site plan must accompany this application.
2022
Part 1: Applicant/ Parcel Identification/ 6�5 W. gjde,- Street
on Applicant: Uf) (,l NA f\)I'Y) 6at.ti(e( Date: t 7 .L -)
Mailing Address: ri'JO t;_ i t AA01,ell'1 j.). .- Phone: I -2-0 - (.7/5 ', `- I "I }
Parcel Number: '3Lif;-1 5I •0/_)'1.-10 t ' ZL - It2( ci nim
lA AJ.14 c44'n 0,s1.0.1`1 _ „i T f
Type of Water System Reason for Application 4 �'" ;fkIVTA
G Public/Community Water System (2 or more tif Building permit a
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
0 Well ❑ Boundary line adjustment
0 Spring/surface water 0 Other(explain)
❑ Other(explain)
0 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 requjre O V E D
System box. A
Part 2: Water Connection Information JUN 17 2022
Complete the section appropriate for the type of water connection being evaluatSON COUNTY ENVIRONMENTAL HEALTH
Public Water System 1A1(L - ,! /;bi ,ET' ,f,t "ri,
Name of Water System: Kro Ltp'Y1;"a"I (` V r-
Water Facility Inventory (WFI) Number: (ALA )`ff.)
(write"none"for two-party) r"
I am the manager of this water system. The water system has been approved for t'4'1 / services. C
There are presently Ii`71i connection(s) in use.This will be the k_%i yik connection. °t
p' )1 am the manageik tJ ip i if-)
his system.This connection will be to upgrade or change the use of an existing
' r --- connection on this system (i.e.: recreational to full time'. Please indicate on the following line the nature
of this change: I.;L,i. (:_I`i't` tytt c �I r"1 4.. tt(t./ry ,i,..- f-(y✓ WC�-t-O/) !
This water system is able and willing to provide water to this (these) connection(s)without exceeding \I
the limits of the water system or any Jimits set by state and local regulation.
,
Signature of Water System Manager t�_/f' ,,t) 0 AU Date I - 2C) •W Z.Z.:
This form may be scanned and available for public view at www,co.nia ion via.us.
J:\EH Forms\Drinking Water Revised 1/25/2018