HomeMy WebLinkAboutWAT2023-00023 - WAT Application - 11/3/2022 (3) WAT Za Z
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MASON COUNTY Shame,WA 985e4
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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 accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant Malt+Karen Eschbach Date: 1 V312022
Mailing Address: 12901 NB Noahshme Rd.Bera ,WA. W528 Phone: 425-301-0846
Parcel Number 322345000012 -
Type of Water System Reason for Application
® Public/Community Water System(2 or more ® Building perms
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcelsl SPL
❑ Well ❑ Boundary line adjustment
❑ Wing/surface water ❑ Omer(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 welt,check the PubllrlCommunlry Water signature required)
System box. APPROVED
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated: JAN 3 0 2923
Public Water System MASON CO11hTy E�L7RG hYENTAI HPAITH,
Name or Water System: Madrona Momingside Beach
Water Facility Inventory(WFI)Number: 50050 (w ite'none'for two-party)
❑ 1 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.
a I am the manager of this system.This conngction Will be to upgrade or change the use of an existing
connection on this system(1.e.: recreational to full time). Please Indicate on the following line the nature of
thischange: N&W env W u, .vb'T.AFYFIT 'rDTff t-St or L0NNf:LT10Ns
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 by state and local regulation.
206-681-3860on h Olson Phone
Print Name of Water System Manager Mica
Signature of Water System Manager Date
This form may be scanned and available for public view,at WW Ws co m riot a w—u.
J:YII Fanns Drinking Wma Reris 427202I