HomeMy WebLinkAboutWAT2023-00338 - WAT Application - 12/22/2023 WAT2023_4033j
415 N.64 SaeN
MASON COUNTY Shohen,WA 99594
COMMUNITY SERVICES stones:36a427-%70,ext40D
Bdba:3602754467,Fat 400
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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 nIde�n-tification
Name on Applicant iNt,`W../: 1 k0—q O-L� Date: Nov 6,2023
Mailing Address: 43/1 355 4U S J: E&,6*%,U- Phone: ' 1 Z$3-33f Sr69Y
Parcel Number: 20 Ai Ilw+..«. (•aw...+A C�. W DMSION 6 LOT 69
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Type of Water System Reason for Application
di Public/Community,Water System(2 or more EkAldmg permit � 3�b 14 '1;PL
connections) Division of land:
❑ Individual water source(one connection), At of Parcels? SPL
❑ Well ❑ Boundary line adjustment
El❑ Other(explain)nrglsurface water ❑ Otter(explain) j
❑If you have more than are residence connected of water system below Ifpease indicate name
applicable-no
to this well, check The PuhliMCwnmundy Wafer signature required)
system box.
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Part 2: Water Connection Information """ °""77) A pP p c
Complete the section appropriate for the type of water connection being evaluated: '` 2�L D
DEC Z?Public Water system I/ALS 023
Name of Water System: LAKE CUs MANS Ems REI CNVIRONMEh'TA(HEA TH
Water Facility Inventory(WFl)Number 035M (write-now for tWG-parly)
❑ 1 am 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.
■ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(ia.:recreational to full time).Please indicate on the following line the nature of
this change: con une
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 Je Mathews Phone (360)BTT-9668
Signature of Water System Manager """"`"` Date Nw6,2m3
This form may be scanned and available for public view at
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