HomeMy WebLinkAboutWAT Application - 2/26/2024 WAT
MASON COUNTY I
EXis�'n
COMMUNITY SERVICESt.
Buil6, P6nnin4Emimnm..IH-1t Community HeJN covVix 6 fio"
415 N 6"Street,Bldg 8,Shelton WA 98584, ��EJ. E��L�r
Shelton:(360)427-9670 ext 400 O Beffalr:(360)275-4467 W 400 4 Elma:(360)482-5269 ext 400
FAX(360)427-7787
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 she plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Michael& Natalie Penn Date: 2-26-24
Mailing Address: 23133 NE 14th Ct., SammamisInPhone: 425-443-8851
Parcel Number: 22132-41-90033
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more El Building permit o0 936
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ Other(explain)
ep acem Remodel (please indicate name
It you have more than one residence connected o em below if applicable—no
to this well, check the Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of water System:
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
❑ 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.
❑ 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.
Signature of Water System Manager Data 2-26-24
This form may be scanned and available for public view at www.co.mason.wa.us.
J:AEH FormsA Drinking AA,i Revised I@5I2016
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