HomeMy WebLinkAboutCOM2022-00057 - COM Water Adequacy - 6/21/2022 .
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WAT
415 N.6th Street
��t MASON COUNTY Shelton,WA 98584
i�'� COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
-_ IictFdir:360-275-4�46(7�,I�x�tt.�4�00
Budding.Ptimmg,e�tmmtmtaI Health Community unity Health Elma: ��1= V C D
Application for Determination of Water Adequacy JUN 21 2022
Instructions ( 15 W. Alder Street
i 1. Complete Part 1. No determination can be made until Part 1 is fully completed.
12. Complete only the portion of Part 2 applying to the type of water connection utilized.
13. Submit completed application,with any required attachments for review.
14. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Po 144. o 6 b rAf Date:
Mailing Address: / 15-S 111v -yer S1p hone: r6,a 4 7e)/ i3T
Parcel Number: 32 00 - 7. -- '61i 0 5'
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Type of Water System Reason for Application,
Public/Community Water System(2 or more IX Building permit elyy 1'1'i•en C�-4�.� �n VG
connections) 0 Division of land: Sthtc" l
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ 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 required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: %.Q`' r` Z 0
Water Facility Inventory (WFI) Number: (95-9 2- (write"none"for two-party)
) I I am the manager of this water system. The water system has been approved for ` E services. There
are presently / connection(s) in use. This will be the 2,..,„,/- 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 willing to provide water to this (these)connection(s)without exceeding the
limits of the water system or any limits s t by_state and local regulation
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Print Name of Water System Manager // ,vi;,._ J j.} ,L& Phone e"�
Signature of Water System Manager - � '���L Date jr 311 -
This form may be scanned and available for public view at www.co.mason.wa.us.
J:4,EH Forms\Drinking Water RCN Ned V2 7,2021