HomeMy WebLinkAboutWAT2024-00286 - WAT Application - 7/20/2024 WAT
MASON COUNTY
COMMUNITY DEVELOPMENT
Pvrml�LssK4rce Cm�m9uIIGIrg.Planning
415 N 6m Street.Bldg a,Shelton WA 96594,
Shelton:isso)4W-9670 eM 400 O aelfair.(360)275-4467 GM 400 O Elmo:060)492-5269 erg 400
FAX(360)427-T167
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 or water connection utilized.
3. Submit completed applicabon,with any required attachments for review.
4. An approved building site plan must accompany this a Nation.
Part 1: Applicant!Parcel Identification
Name on Applicant i IA6514 if' Date:
Mailing Address: Sf1;k DlNnrPC 62. jiJ. Phona: �ib Y3.? 4r47 !'ps{�a ✓`
Parcel Number (MLJ (
Type of Water System Reason for Application
® Public/Community Water System (2 or more ® Building permit'jI .,I azq- L)L)q I gJ
connections) ❑ Division of land:
❑ Intlividual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explam)
❑ Replacement or Remodel(please indicate n
ff you have morn than one residence connected of water system below 4 applicable-no
to this well,check the PublWCommunity Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:A P P R O 1 E
Public Water System V
Name of water system: 2 /IV MASO�NCOUN E5'NRCR chfq(NE1(
Water Facility Inventory(WFI)Number 3156g RET
(write-none-for two-party) �/��/
I am the mane of tlt'i;Mw�ter s em.The waters stem has been a for 7 f0 services.
There are presently 1 n r nnec[lon(s)in use•This will be the N!G connecaon.
❑ 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 lime).Please indicate on the following line the nature
of this change:
This water system is able and willing to provide water to this (these)connedion(s)without exceeding
the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager. Date
This form may be scanned and available for public view at WW
1 Dmpng W ___.