HomeMy WebLinkAboutWAT2024-00300 - WAT Application - 9/14/2024 WAT 2Qgc__ 00300
MASON COUNTY 411 N.b°Stmr
4 S iefta,y A 98584
Public Health & Human Services Sheltaa:360127- 70.Bt 400
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Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made unfit Part 1 is fully completed,
2. Complete only the portion of Pad 2 applying to the type of water connection utilized.
3. Submit co npated application with any required attachments for review.
C An approved building site plan must accompany this application
Part 1: Applicant/Parcel Identification
Name of Applicant: William Renne Date:
Mailing Address: 3712 Cabnial Late SE Port Oritard,WA 9WIS Phone: 253-527-2151
Parcel Number: 122297890074
Type of Water System Reason for Application{ c7
Public/Community Water System(2 or more 99 Building permit aL.Daoa�—Gb 1
connections) ❑ Division of land
❑ Individual water source(one connection), If M Parcels? SPL____
❑ Well ❑ Boundary line adjustment
❑ Spring/surfacewater El Other(explain)
CI Other(explain)
❑ Replacement or Remodel(pie iou indicate name
If you have more Man one residence connected of water system below y applicable- no
to this well,check the Pubflc/Community Water signature required)
System box. APPROVED
Part 2: Water Connection Information SEP 19 2024
Complete the section appropriate for the type of water connection being evaluated: MASON COUNTY ENVIRONMENTAL HEALTH
Public Water System
Name of Water System: `�p
Water Facility Inventory(WFI)Number: 0 t (write'none'for two-party)
1k I am the manager of this water system.The water system has been approved for_(services.There
are press^ify G—connection(s)in use.This will be the�Qconnection.
❑ 1 am Me manager of this system.This connection will be to upgrade or change the use of an exis.ing
connection on this system I.e.:recreational to full tints).Please indicate on fine following line Cie,azure of
this change'
This water system is able end willing to provide water to this(Mesa)connection(s)without axe sefng the
limits of the water system or any limits set by state and local regulation. �.x
Print Name of Water System Manager r\t�A.r\ I/tA/i l Phone
Signature of Water System Manager l/ l fy/ Date -"
This fund may be acwumd and avaaabie for public view at www.masoncounllnvaaav
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