HomeMy WebLinkAboutWAT2024-00096 - WAT Application - 2/13/2024 MASON COUNTY
COMMUNITY SERVICES
Wild.,Pbnnhy Em..m HsIMCammuniry HallF
415 N 6-Street Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4 Beffair(3660)42787xt 400 4 Elms:(360)482-5269 ext 400
FAX
Application for Determination of Water Adequacy
Instructions
Complete Pan 1. No determination can be made until Part 1 is h Ilv competed
�2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit completed application,with arty required attachments for review.
4. Ana roved buildingsite Ian must acoom an this aElplication.
Part 1: Applicant/ Parcel Ident� aticir I ' [�
Name on Applicant �,^, �nl`/�/ t"l Da �- � /_1
Mailing Address: 9fYt-nj � �1'IX Z-7/t�lF 'is:
Parcel Number: 1 _154 -(JlLX2
Type of Water System Reason for Application
,.f Buildin ermitBV
Public/Community Water System (2 or more /�-+ g P
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surfam water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below ff applicable-no
to this well, check the Publiccommunity Water signature required)
System box. A P PR OD
Part 2: Water Connection Information MAR 13 2024
Complete the section appropriate for the type of
"tePublic connection being Water System valuatYlASON COUN1yENWRONMENTA(NEgITH
Name of Water System: nd
Water Facility Inventory(WFI)Number.
j (write"none'for two-party)
I am the manager oft 's w ter system.The water system has been approved forqZservices.
There are presently connections)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 system (i.e.:recreational to full time).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 an im t set by state and local regulation.
Signature of Water System Manager. Date
This form may be scanned and available for public view at www.co.mason.wa.us.
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