HomeMy WebLinkAboutWAT2022-00253 - WAT Application - 7/22/2022 `300 4 l cS�9 '17r Ld
WAT Zi - �
415 N.0 Strecr
MASON COUNTY Shelton,WA 99594
a— 11 COMMUNITY SERVICES She0on:360-427-9670,W.400
Hclfair.360-275-4467,Ext.400
a,�ama wn.:g x Elma:360.482-5269,Ext.400
Application for Determination of Water Adequacy
Instructions L�
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: Applicantl Parcel Identification
Name on Applicant. TWC EnfiCypruCe Date: Lo»
Mailing Address: % 06V 2603 G1(4PL40/ Phone: 360 cf�o 2QlQQ
Parcel Number: 7 mtg -50-00070
Type of Water System Reason for Application
Nf Public/Community Water System(2 or more M' Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ 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 requirecf� n
System box. f`� l�P pO 1 ,
Part 2: Water Connection Information "1' 2 V�D
Complete the section appropriate for the type of water connection being evaluated:a�'4000ry ? �14
/ Public Water System 7YREROHMEN1ggtN&1(l
Name of Water System:_ym ['' r 6Amft^'fl. G 5/
Water Facility Inventory (WFI)Number: rgb37� (write-none" for two-party)
U' I am the manager of this water system. The water system has been approved foreservices. There
are presently connection(s) in use.This will be the y�_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 lie: recreational to full lime). 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. c�
Print Name of Water System Manager // 6i't"1 Ili
Phone �r- .t-2 U��
Signature of Water System M t`anager ' li ' Date �-3-d ✓�
This form may be scanned and available for public view at www co.mason.wa.us.
JTH forms\nrirtUne Wxrar Rcvimd 1270021