HomeMy WebLinkAboutWAT2023-00235 - WAT Application - 7/26/2023 ;cIVED
ENVIRONMENTAL SEP - 6 2023 WAT - 6002 5
HEALTH W. Alder Street
415 S.6°Stnzl
MASON COUNTY SheMn a'A vs594
GCOMMUNITY SERVICES SNOW:360.137%1).h:«411
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Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination an 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 scxompany this application.
Part 1: Applicantf Parcel Identification
Name on Applicant Greg Ericsson Date: 0 7/2 612 0 2 3
Mailing Address: PO Box 3372 Phone:
-Parcel Number 22206-54-00012 - - -
Type of Water System Reason for Application
JP Public/Community Water System(2 w more ® Building psrmx b1_0 a,0a3`ol,055
connections) ❑ Division of land:
❑ Individual water source(one connection), a of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water❑ Other(explain) ❑ tither(explain)
❑ Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below if applicable— no
to MIS wef, check the PublinCommum1y Waler signature ra(Al#ap/'�r�O VED
System box.
Part 2: Water Connection Information u;g^4COU NOV 13 2013
Complete the section appropriate for the type of water Connection being evaluated: FRET NMENT4L HEALTH
Public Water System
Name of Water System: Tahuva River Valley Water District
Water Facility Inventory (WFI) Number. e7115N (write 'none' for two-parry)
tD I am the man agar of this water system. The water system has been approved for 190 services. Thera
are presently 712 connection(s)in use. This will be the '47 connection.
E3 1 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: A meter is already installed for this proptarty.
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.
Pnnt Name of Water System Manager Andrew Noble Phone 360A274)654
Signature of Water System Manager �'c—�—`� /F' Zf,r"o,#JOate
This form may be scanned and avallable for public view at by cei,co, l.ya.