HomeMy WebLinkAboutWAT Application - 9/15/2022 WAT
•
MASON COUNTY
7,),
COMMUNITY SERVICES �u-�nzint
Building Planning Environmental Health,CommunitY Health
25,14
415 N 69" Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair:
87 ext 400 Elma: (360)482-5269 ext 400
FAX(360)427 7
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1, No determination can be duntil
th Part 1 is e of water cl nnectioized.
2. Complete only the portion of Part 2 applying to the
type
3. Submit completed application, with any required attachments for review.
4. An a roved buildin site Ian must accom an this a lication.
Part 1: Applicant/ Parcel Identification
Name on Applicant: FRED AND KATHY KOHOUT
Date: " I�l 'L� �
Mailing Address4608 CREEKVIEW LN, OLYMPIA, WA 98502Phone: 4258024818
Parcel Number: 42213-23-70840
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit alai 2.62_2_ ZO
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
Well 0 Boundary line adjustment
0 Spring/surface water 0 Other (explain)
❑ Other (explain) e laceme or Remodel (please indicate name
of water system below if applicable— no
If you have more than one residence connected signature required)
to this well, check the Public/Community Water g
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:
Water Facility Inventory (WFI) Number:
(write "none"for two-party)
❑ I am the manager of this water system. The water system has been approved for services.
There are presently connection(s) in use. This will be the
connection.
ade
or
e the use
an
ing
❑ I am the manager of this myseem ecreational tolfull ton ime)ill be Pleaser indicate on tghe follow ngfline the tnatture
connection on this syste
of this change:
This water system is able an
willing
glto provide
imits set by state to this
ochere) connection(s)without exceeding
the limits of the water systemor any
ation.
Signature of Water System Manager
Date
vailablekfor public view at www.co.mason.wa.us.
This form may be scanned and a Revised I125/2018
J:'EH Potms\Drinking Water