HomeMy WebLinkAboutWAT2023-00375 - WAT Application - 12/18/2023 wATaoa�� 003
MASON COUNTY
COMMUNITY SERVICES
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HE LT a''�"°°m"m4Erwhmm dReJMfamnngHJM RECEIVED
415 N 6-Street Bldg 8,Shelton WA 98584, pQ
Shelton: (360)427-9670 ext 400 O Behar: (300)2754467 ext 400 O Elma: (360)482-V5288,e>�a0((]23
FAX(360)427-7787 tIh, 6
Application for Determination of Water AdegW4 W. Alder Street
Instructions
11. Complete Part 1. 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. 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: BRYNN&STEPHEN BLACK Date: 11-29-2023
Mailing Address: PORT
LMD OWNS
72211260 Phone: (503) 577-4410 (503) 927-7867
Parcel Number: 12119-53-00042
Type of Water System Reason for'Applinlicca�ation n 4�)p
® Public/Community Water System (2 or more 16 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)
❑ Replacement or Remodel (please indicate name
ff you have mole than one residence connected of water system below if applicable—no
to this well, check the Public/Community Wafer signature required) -q
System box.
Part2: Water Connection Information �gs0,y�0�N✓gH/�,�0�/C
Complete the section appropriate for the type of water connection being evaluated:
Public Water System A R�NyF
Name of Water System: HARTSTENE POINTE WATER-SEWER DISTRICT
Water Facility Inventory(WFI) Number: 31569-0
(write"none"for two-party)
❑ I 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.
fit 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.: recreatlonal to full time). Please indicate on the following line the nature
of this change: Building a residence
This water system is able and willing to provide water to this(these)connection(s)without exceeding
the limits of the water system or any limits set bystate and local regulation.
Signature of Water System Manager Date 11-20,2023
This forth maybe scanned and available for public view at www.co.mason.wa.us.
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