HomeMy WebLinkAboutWAT2023-00333 - WAT Application - 11/6/2023 WATT —0033
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MASON COUNTY Shelton.lt'n ueiX4
COMMUNITY SERVICES Shetioe 3614477-9670.Lxn-+10
Belun:3602-1` 1N 7 Lw.400
11rvd,11-n.y Flnv: 360482-i2o9.1 40)
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Pan 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 Identification /
Name on Applicant ') n-mo�tn4-1i ko,&y i Date:
Mailing Address: TV Y, 8,bs Phone:
Parcel Number Jzkos- -5L- ago-Cr
Type of Water System Reason for Application ,�yyJJ�
le PublidCommllnity Water System(2 or more 1d Building permit fpo; 93'C)140T
connections) ❑ Division of land.
❑ Individual water source(one connection), s of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) —
❑ Replacement or Remodel(please indicate name
1/you have more than one residence connected of water system below if applk i-no
to this well, check the Public/Community,Water signature required)
System box.
Part 2: Water Connection Information ppli 1
Complete the section appropriate for Me type of water connection being evaluated: O y
n vEc FD
Mq
Public Water System 5�.4�p;,, ZQ2D2
Name of Water System: r1�0'yMENJq
Water Facility Inventory(WFI)Number: d r,p REr 4 (Jfl
(wme-none-for tiro-party)
I am thin manager of this water system. The water system has been approved for services.
There There are presently 1�5—connection(s)in use.This will be the 40 onnection.
1
❑ I am the manager of this system.This connection will be to upgrade or change the use of an exist 3g
connection on this system le.:recreational to full time). Please indicate on the following line the nature
of this change:
i This water system is able and willing to provide water to this(these)connection(s)without e':ceedmg
the limits of the water system or any limits set b late and local regulation.
Signature of Water System Manager Date 2
This form may be scanned and available for public view at www.co.mason.witi
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