HomeMy WebLinkAboutWAT2024-00045 - WAT Application - 12/1/2023 WA T jD -.Jd6L�1—
MASON COUNTY
COMMUNITY SERVICES
415 N 6o Street,Bldg 8,Shelton WA 98584,
Shelter:(%0)427-9610 en 400 o Beffe,(W 60)42�58'xt 400 Elms:IWO)482-5269 ee 400
Application for Determination of Water Adequacy
Instructions r..W.... ,....,.
t. Complete Part L 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.
4Submit completed application,with any required attachments for review.
M approved bi iilding site plan must accompany aDecompany this application.
Part 1: Applicant] Parcel Identification t�
Name on Applicant:�� � "' /r/�1
Mailing Address: .,J9L/a� /q y140 L� /<t2xa` af�l4ofSe`. ��
Parcel Number /"i. __y"I`J 900_�?k
Type of Water System Reason for Application
/X PubliclCommunity Water System (2 or more �l Building permit -2)td&?_L4
connections) ❑ Division of land'
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/sorfaoe water ❑ Other(explain)
❑a Other(explain) ❑ Replacement or Remodel(please indicate name
if you have more than one residence connected of water system below if applicable—no
to to this well, check the PuWic/Communify Water signature required) 7�
System box. 9
py ^�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
Wale Facility Inventory(WFI)Number
(wnee'none"for two-party) �/
yID I am the manager o is ater system.The water system has been pq{7 ro�±ed fch 1 1�services.
There are presents). ' el connectorl in use.This will be the 1.1 connect- ion.
❑' 4 am the manager of this system. This connection will be to upgrade or change the use of an existing
.gpmnectwn on this system (i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
,v This water system Is able and willing to provide water to this (these)connection(s)without exceeding
the Jim of the water system Or
I at by st to and local regulation.
` 1)�/q Date Sign Manager
'. T ' ad and available for public view at www.co mason wa.us.
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