HomeMy WebLinkAboutWAT2024-00141 - WAT Application - 3/4/2024 WATB�- _
MASON COUNTY
COMMUNITY DEVELOPMENT
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415 N 6° Street,Bldg 6.Shelton WA 98584.
Shelton:(360)427-9670 ext 400 O Better.(3W 275.4467 ext 4W s Elina: (360)482-5269 aid 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
i. 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 an must accompany this application.
Part 1: Applicant/Parcel Identification
Name on Applicant: Todd Sher6ck Date: 314/24
Mailing Address: PC Box 1841 Phone: 360509-0890
Parcel Number: 32214-51-06034
Type of Water System Reason for A'pp\lication/ moo,
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ElPublidCommunity Water System(2 or more ElBuilding permit
connections) ❑ Division of land:
❑ Individual water source(one connection), a of parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Re coal(lease indicate name
If you have more than one residence connected of water system by�w/FpgQlicable-no
to this well,check the PublioyCommuniry,Water signature required) II'"'�
System box.
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Part 2: Water Connection Information �1430N� R CON 0 y 10zy D
Complete the section appropriate for the type of water connection being evaluated: ry40
Public Water System RFT NMFNTq(y�/Tit
Name of Water System: w r{ A iS
Water Facility lnventory(WFI)Number: S"O d3.Sli'
(mite"none for two-party)
❑ 1 am the manager of this water system.The water system has been approved for_services.
i There are presently connection(s)in use.This will be the eonnscbon.
i 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: art- prt5 Nina
I This water system is able and willing to provide water to this(these)connecson(s)without exceeding
the limits of the water system or an ly icons set a anE letaLfegulalpn.
:.� 314124
Signature of Water System Manager ���^'�%� Date
This form may be scanned and available for public view at JrQYlvsLg.ma£vn�yta_.iJ;.
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