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HomeMy WebLinkAboutWAT Application - 5/30/2023 13/-D2 -01. _ - MASON COUNTY S' . <' COMMUNITY DEVELOPMENT Shelton:3t0-42l 7 Ext.4(o e BeMir:360'2 5 Ex_.400 ., . m rern Atattame Center.[Wading. x. , .nnang Elmo:360-4 Application for Determination Adequacy RECEIVE , of Water MAY 3 0 2023 instructions 1.21: Complete Part 1. No determination can be made until Part 1 is tally r-d Cornpleie 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 accom an this a lication, Part 1: Applicant/ Parcel Identification Name on Applicant: 4(II)jj: 1 ' Date: -� Mailing Address: �J�Z ��'f, 7o:m7re rr1�,��; Phone: i l 0 / �ii Parcel Number: � ? fS 'TypeofWater SystemReason for Application 'L_Public/Community Water System ( 0 Building permit connections) 0 Division of land: Individual water source (one connection), #of Parcels? _ SPL- D Well 0 Boundary line adjustment (I, ❑ Spring/surface water that(explain) 0 Other(explain) ❑ Replacement or Remodel (please indicate nay`'€ J!'you have more Man one residence connected of water system below if applicable-no Kt..to this weft; check the Public/Community Water signature required) ...' . -" `,v,tem box.ft 2: Water Connection Information , ;ralete the section appropriate for the type of water connection being eval led: Jo/public Water System ��e 'rS`T' c ,�� 4 ue3 f !dame of Water System: f e- tNater Facility Inventory (WFI) Number: .. + P35" — r IP (write "none" for two-party) r I am the manager of this water system. The water system has been approved for ______services. i 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 sys (i.e.: creational to full time). Please indicate on the following line the nature .. r f this change: rsi ��-.e..-i 4411 ;: his water system is able and willing to provide wa o this (these) connection(s)without exceeding ,;.. `4. e limits of the water system or any limits state and local lotion. Date -a? 0.2 ''t ture of Water System Manager __._. '.t t- ..i�, 1 pay be scanned a available for publi w atvlrwvrr.c�.l�anaSOfl Wa.0 r. Revised 4/4420 r..