HomeMy WebLinkAboutWAT2023-00072 - WAT Application - 4/13/2023 WAT 2623 - cev-ra
N.6'h Street
MASON COUNTY she ton WA 98584
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" 1, COMMUNITY SERVICES s -427-9670, 400
.✓` / Bel air:3Ti0-275-4467,C 400
Building,Planning,Environmental Health,Community Health
9• µ Elma:360-482-5269,Ext.400
APR 13 Luf_3
Application for Determination of Water AdeElaW Alder Street
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 / f
Name on Applicant 1! -t:&CA(k�U 4fldQ1e:
Mailing Address: Phone:
Parcel Number: 3- -k .50 000 5"D,,,-
Type of Water System Reason for Application
A. Public/Community Water System (2 or more X Building permit Biel 2D23— Cip 3qt "I-
connections) ❑ Division of land:
0 Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other (explain)
❑ 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. /� n n
Part 2: Water Connection Information A P P ROVED
Complete the section appropriate for the type of water connection being evaluated: MAY 02 2023
Public Water System
MASON COUh', ENVIRpNMENTAL HEALTH
Q RET
Name of Water System: ��JdyA,ct � �,, � l'
Water Facility Inventory (WFI) Number: 'f ci i (write "none" for two-party)
fit—I am the mana r of this water system. The water system has en pproved forv(7f services. There
are presently L..connection(s) in use. This will be the /Cj- 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.: 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 set by state and local regulation.Print Name of Water System Manager PhoneZa c ,0117/ `L
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
1:1EH Forms\Drinking Water Rev i.cd 4,27r2021