HomeMy WebLinkAboutWAT2024-00086 - WAT Application - 11/27/2023 wnT 2az� - 6Uo�
MASON COUNTY
COMMUNITY SERVICES
BUWPne Vbnniny,Eiwi,anmeaal eeaNh CammunOy HeulOi
415 N 6-Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4 Bellew (380)42(360)
M 400 4 Elms: (360)4825269 ex1400
FAX
Application for Determination of Water Adequacy
Instructions
1, Complete Part/. I la o8 ionination can be made until Pad'1 is fully completed..
12. Complete only the portion of Part 2 applying ro the type of water connection utilized
3:. Submit completed application,with any required attachments for review.
4. An approved building site plan mustaccom am this a2 lication.
Part t: Applicant/ Parcel Identification
Name on Applicant:M I . _ . LL(L Date: lka'7-2c) 2 -�
Mailing Address: ?C -6px IS I't jl,0k , Jn �/t3t3� Phone: 3100490 (a3 wS
Parcel Number: SLI8 -SY-02YZ7� !^
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Type of Water System Reason for
rryApplication 1
( Public/Community Water System (2 or more ❑ Building permit
/ 1 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 required)
System box. /1/R`
O
Part 2: Water Connection Information MASQ '%S ? VFW
Complete the section appropriate for the type of water connection being evaluated: NCQ�NTy
Public Water System FN�RQNM
Name of Water System:
!1 r ./ )1#�
Water Facility Inventory(WFI)Number. 8?oss to
(write'none*for two-party)
01�1 am the manager of this water system.The water system has been approved for a4 77 services.
There are presently connection(s)in use.This will be the 2.1; 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 able and w ling to provid water to this(these)connection(s)without exceeding
the limits of the water system of any lit 'is sO,t Py state and loml regulation.
Signature of Water System Manag, Dale Ff-g 2-L 2t1 Z y
This form may be scanned and available for public view at www cia mason.wa.us.
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