HomeMy WebLinkAboutWAT2024-00123 - WAT Application - 2/12/2024 WAT�L�-
MASON COUNTY
COMMUNITY DEVELOPMENT
4 415 N 61°Street,Bldg 8,Shelton WA g8584,
MAR 1 2 2QII11ellon:,(360)427-9670 ext 400 O Belfair:(360)2754467 ext 400 0 Elm: (360)482-5269 ext 400
FAX(360)427-7787
Bv— .
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 14XL J /-t /62a L Date, 2- Z �/ - L(f
C
Mailing Address: 339dO 72410J &P ./;r711N Phone: (,,6r) Q/o -07?9
Parcel Number: L22.23-5-0- 0(V
761 G n+•rls e dn��r
Type of Water System Reason for Application
Public/Community Water System (2 or more 111�Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #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 below if applicable-no
to this well,check the Public/community Water slgnaWte
System box. //''ii O VE D
Part2: Water Connection Information AIR 152024
Complete the section appropriate for the type of water connection being 201JdtCn��� y EREr NMENTAL HEALTH
Public Water System
Name of Water System: aA�U-T fnZ UJA-,-'--a �J._S i�lw��T 2-
Water Facility Inventory(W Fl)Number. P-q G5t;-1°
(write"none'for two-party)
zs3
Ild I am the manager of this water system.The water system has been approved for imervices.
There are presently 2q :5 connection(s)in use.This will be the Z y 4 connection.
❑ 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)connection(s)without exceeding
the limits of the water system or any limits set by state and local regulation. �,.,,/7
Signature of Water System Manager. Date //4* 7 ZOL9
This form may be scanned and available for public view at www.co.mason.wa.us.
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