HomeMy WebLinkAboutWAT2024-00240 - WAT Application - 5/17/2024 WAT gV�L-- �
MASON COUNTY 415,N.W Sheet
Shelton,WA L 400
584
Public Health & Human Services shclnm:3601zz967o.Ex00
Belfeir.364275-4467,Ext.406
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can he 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 f � —1
Name on Applic�a7nt:LrYy�t 1 ynyvw FT/1 ,�} Jate: 5 1 ! a
Mailing Addressi',0•13640.�-k I, Phone:
Parcel Numbera-a `V(t�J ( '0020 $'i
Type of Water System Reason for Application
/
Public/Community Water System(2 or more IN Building permit 5 � 0 7
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springlsurface 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 signature required)
System box.
Part 2: Water Connection Information APPROVED
Complete the section appropriate for the type of water connection being evaluated:
Public Water System JUN 1 1 1014
Name of Water System: r Ml >° y'[� CDIh/Yv'/4 T/H - RET tTH
.Water Facility Inventory(WFI)Number. �7C (write"none'fortwo-party)
❑ I am the mana r of this water system.The water system has approved for IA" services.There
are presently 33 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)connections)without exceeding the
limits of the water system or any limb sweet y state and Vocal egulation.
Print Name of Water System Manager !/ / " '� Phone
/
Signature of Water System Manager, " 7y r 4 L11 Date
This form may be scanned and available for public view at www.masoncountywa.gov
1:t FmmS Ddnli WaW Revtst 05MM024 Paige 1 of2