HomeMy WebLinkAboutWAT2023-00244 - WAT Application - 4/26/2024 wAT�J2z3. OOzy�
144 40 MASON COUNTY
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Public Health & Human Services
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No detamr ination can be made until Part 1 is Mly completed,
2. Complete only the portion of Part 2 applying to the type of water connector util2ed.
3. Submit completed application with any required attachments for review.
4. An aPpruved building site plan must accomplany this awhcatOn.
Part 1: Applicant/Parcel Identification .f / -f /
Name on Applicant: �". vi t y c.�y�2-
.a Date: ! �-/�
Mailing Address: fad `Z7 f G I Plane: 6 �' J y .
Parcel Number: fN f4oyd
Type of Water System Reason for Application
�.1 Public/Community,Water System(2 or more Building permit
connections)
❑ Diviof land:
k
❑ Individual water source (one connection), of Parcels? SPL
❑ Well ❑ Boundary the adjustment
❑ Spring/surface water
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel (please Indicate name
it you have more man one residence connected of water system below if applicable -no
to this we/f, check the Public(Community, water signature refill"APPROVED
P
System box. A P p O 1 E
Part 2: Water Connection Information APR ` V ` �
MASONCOUN R ON 024
(EN
Complete the section appropriate for the type of water connection being evaluated: TYEN
✓RONMENTq(HEkTH
Public Water System RET
Name of Water System: [' Ik2r4 !}
Water Facility Inventory(WFI)Number:—Pi� (write*none*for two-party)
I am the manager of this water system. The water system has been approved forservicee. There are presently_V connection(s)in use. This will be the I connection.
❑ 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:
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.
Print Name of Water System Manager lily Phone 1_,q
Signature of Water System Manager GJj�
Date L� '�L z�
This form may be scanned and available for public view at WWW.masoncountywa oov
lair Forms\Drinking Water
Revised 04/12/2024
Pagx I f: