HomeMy WebLinkAboutWAT Application - 1/22/2024 WAT
MASON COUNTY
COMMUNITY SERVICES xl) NfNCA
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.1�ON�'�`` 4l5 N 6rr Stn:et, Bldg 8,Shelton WA 98584, �ECF IV E
N on:(360)427-9670 ext 400 4 Belf FAX(30) 75-4677 exit 400 0 Elma: (360)482-5269 ext 400
427-7787 JAN 22 2024
Application for Determination of Water Adequacy 615 WAlder Street
Instructions "
t: Complete Part 1. No determination can be made
until Part 1 is fully wmoleted.
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. Ana roved buildingsite Ian must accompany this application.
Part 1: Applicant/ Parcel Identification
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Name on Applicant:
Mailing Address: ?4fX 7G �Il�j�rf- Phone: 24G aw 3'�—
Parcel Number: _=7�—
Type of Water System Reason for Application
Public/Community Water System (2 or more ❑ 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) a lacemen r Remodel (please indicate name
If you have more than one residence connected MU er system below if applicable—no
to this well, check the PubliclCommunily,Water signature required
System box. .f0.J tWIIOCU I
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: :?: ! !I> -----
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
❑ 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 (i.e.: recreational to full time). Please indicate on the following line the nature
of this change: —
This water system is alle 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.
Signature of Water System Manager Dare ._
This form may be scanned and avail is view at WJNco.mason.Wa.us.
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