HomeMy WebLinkAboutWAT2023-00057 - WAT Application - 3/14/2023 RECEIVED
MAR 14 2023 WAT 20 23 - 000 5' -
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. Alder Street 4tsx.66Street
MASON COUNTY Shelton,WA 98584
COMM SERVICES Shelton:360-427-9670,Ext.400
`trCIT - COMMUNITY j x x Brif„ir 360-275 4467,Fxt 400
bulidl,iFirming,evIrawnental Nsldti commu,ilq tie, Elm:360-482-5269,Ext 400
• Application for Determination of Water Adequacy •
Instructions
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.
3. Submit completed application,with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/Parcel Identification
W� _,, ��.
Name on Applicant L, 1 1.OU156 i IUUx.1 I l�ur►1 ate: l3'�1.23
Mailing Address: '-}4',1- A31 PL SC Phone: I.21y,601. 440'4c4
Parcel Number: j22211.4-0-01021- l 1 WA 9002-k
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more X Building permit -aid 2.0v,• ODZ IS
connections) ❑ Division of land:
O Individual water source(one connection), #of Parcels? SPL .
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
0 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 y l„ 7
ljl
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated: APPROVED
• Public Water System
44123
Name of Water System: 0-ckonte. Lcc\t J\9,,Vf-r- iis -ArMASONCOUNTYENVIRON
Water Facility Inventory(WFI)Number. 0.9i 3 (write"none'for two-party) REr NTAL HEALTH
tam 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.
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.:r eatlonaall °full time).Please indicate on the following line the nature of
this change: AZ zt/ c /' ,�=u V `i .
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 set by s to and local regulation.
41
Print Name of Water System Manager i!'a/ c>O �i :% Phone
Signature of Water System Manager Date S-� V-av:0
This form may be scanned and available for publl view at www,co,mason,wa,us.
.1:\Fa Forms\Deakins War Revised 4/27/2021