HomeMy WebLinkAboutWAT2023-00056 - WAT Application - 3/29/2023 WAT2 - OtTY- /I
,,''' MASON COUNTY
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MAR 1 9 2023 •
415 N 691 Street,Bldg 8,Shelton WA 98584, ---
r:F C t! Shelton:(360)427-9670 ext 400 % Bel►air:(360)275-4467 ext 400 h Elina:(360)482-5269 ext 00
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1 `�E� FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
i. 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: Applicantl Parcel Identification .
Name on Applicant: 3/1h / Q-Qii.SPn Date: 3-C
oz k /-v-4, Phone: �'. 5r - � .�
Mailing Address: /A.Z� / • -'7 _..
„Parcel Number: J - 0 5 6 a /.
Type of Water System Reason for Application
jam,Public/Community Water System(2 or more tr Building permit . )11c l G02.7- c6-2 71-
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
0 Well 0 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 required)
System box.
IPart 2: Water Connection Information ^
Complete the section appropriate for the type of water connection being evaluated: [1
Public Water System R
Name of Water System: t-c%" i$ V
Number: .�G, i�) 0 13 • COU �'�eN.1, �?,�
Water Facility Inventory(WFI) /
(write"none"for two-party) /1)8 -4(s.'j�` C•:
0 I am the manager of this water system.The water system has been approved for__ _services, y�LiH
There are presently connection(s)in use.This will be the_ connection.
1 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: 4JPGt:Al7Ai .cCuzprAr'K',v_A4 7Z fag 4.. rpn6
This water system is able and willing to provide water to this(these)connection(s)without exceeding
the limits of the water systern or any limits set by state and local regulation. -ry
Signature of Water System Manager ,, Date— 0 -/ 7 - )
This form may be scanned and available for public view at www,co,mason'wa.us.
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