HomeMy WebLinkAboutWAT2024-00259 - WAT Application - 6/5/2024 WAT
MASON COUNTY
COMMUNITY SERVICES
&miry Pa�Emmmm N C�X
415 N 6' Street,Bldg 8.Shelton WA 98584,
Shelton.(360)427-9670 ext 400 4 Beaaic(360)275-4467 ext 400 i• Elma:(360)482-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
1. 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 aoccirripany this application.
Part 1: Applicand Parcel Identification ,l
Name on Applicant: Rblo lw11 \ Lc Date 1u-5-- Q0a`4
1
Mailing Address: ITin, NZ C1T-s 4 io , C ap a ne 3i¢O•- -71lb -S 335
Parcel Number: a^5--✓ 3l0-�� ro004\o
/l Type of Water System ��`///��l Reason for Applicatiti'ofn ,l
1QJ Public/Commundy Water System (2 or more Building permitIBLDROp14_ou744
( � connections) Division of land:
❑ Individual water source(one connection), g 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 belo� ble—no
to this Well, check the Public Community Water signature required)A PRO\/G D
System box. v C V
JUL 11 2M
Part2: Water Connection Information MASON COUNTY ENVIRONMENTALHEALTY
Complete the section appropriate for the type of water connection being evaluated: RET
l` Public Water System
Name of Water System: (1C..h Cv,hi,
Water Facility Inventory(WF Number. N9100 Lk
(write"none"for two-party) 2,.�
1 am the manager of this Water system.The water system has been ap roved for*A services.
There are presently�b connection(s)in use. This will be the�conneclion.
❑ 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 willing to provide water to this(these)connections)without exceeding
the limits of the water system or any limits set by state and 1 regulation.
Signature of Water System Manager Date 10,5-awtiii
This form may be scanned and available for public view at www.co.mason.wa.us.
J1EH Forrv\Drinking Wnu RcvisW 1/252015