HomeMy WebLinkAboutWAT2024-00293 - WAT Application - 7/31/2024 WAT2D. � gg3-
415 N.&Strew
MASON COUNTY Shelon,WA 98584
0 COMMUNITY SERVICES Shelton:360427-9670,Exc 400
Rdfdn 360-275i 7,Ext 400
Ehm:360482-5269,&t 400
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 ryA
Name on Applicant y�/Z£{ ldN�Z L Dale: 71A op �/
Mailing Address:uZaar!y Cr- 0ndKj(, ,41i '4 Ph":
Parcel Number. 31907-50-00110 *3ID, �.4-771-�a-4IS70-:Z
.l Type of Water System Reason for Application �pf/�k�a PublidCommunity Water System(2 or more Building permit Kg V4—(/u /7
connections) ❑ Division of land:
❑ Individual water source(one connection), Al 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 wait, check the PubliaVommunity,Water signature required)
System box.
Part 2: Water Connection Information �'I P P R O V E
Complete the section appropriate for the type of water connection being evaluated: rCT 0 1 2M
Public Water System MASON COUNTY ES19,ROWEVAL hEALTH
Name of Water System: Madrona Park
Water Facility Inventory(WFI)Number.. D57933 (write'none-for two-parry)
❑ 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.
le I am the manager of this system.This connection will be to upgrade or charge 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: Inactive to Active Connection
This water system is able and willing to provide water to this(these)connections)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Brandy Milroy Phone 3OM775248
Signature of Water System Manager_. ___-_ _ Date 07126=24
This form may be scanned and available for public view at 1et1ar8,tmes,maeu,{�.
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