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HomeMy WebLinkAboutWAT2023-00057 - WAT Application - 3/14/2023 RECEIVED MAR 14 2023 WAT 20 23 - 000 5' - W _:. . , . 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