HomeMy WebLinkAboutWAT2024-00112 - WAT Application - 3/26/2024 MASON COUNTY
COMMUNITY DEVELOPMENT
Fe,mlt MvS me Cerra,8WIAiM mannim
415 N 61°Street, Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 A Belfaic (360)2754467 ext 400 O Elm:(380)482-52289 ext 4W
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 site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: STEPHENS Date:
Mailing Address: 17681 E ST RT 106, BELFAIR Phone:
Parcel Number: 22212-58-00034
Type of Water System Reason for Application /1� —
I1 Public/Community Water System(2 or more 01/ Building permit 5Lb9-V` 4-609(o I7
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
I J 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 belpw If applicable—no
to this well, check the Public/Communtly,Water signature requiredqP b
System box. R
Part2: Water Connection Information R bqR �VF
Complete the section appropriate for the type of water connection being evaluated: ONCOUNryfN R� �144 O
Public Water System RAFT HM474Lha a
Name of Water System: ag/Afk a-1646dz_- 1'! %y,1 f
Water Facility Inventory(WFI)Number. D.s3S2p
(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: ly11 "ar-i
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 Imi t by state and cal regulation.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
I IEFI Fans\Dn.A,W14a Revised IMM18