HomeMy WebLinkAboutWAT2024-00212 - WAT Application - 6/6/2024 i
MASON COUNTY 'n'" e'2e"
Public Health & Human Services B �.ir 3r 2754Mi.FAQ 4�ea
Application for Determination of Water Adequacyt P r 1�
Instructions fi ROVED
t Complete Pan 1. No determination can be made until Pad 1 is fuM c=1e0r?4
1. Complete only the portion of Part 2 a an be to the type a water conn9. Submit completed application with any required attachments for revieMEHTAI H"4. Ana roved buildin site Ian must accom an thi liation. HEALTH
Part 1: Applicant/Parcel Identift ation
Name on Applicant: -
Date:
Mailing Address:
Parcel Number: of11 ,_• , y
Type of We or —15— DDe2/^"�1O—r
ys em Reason for Application
1� PubliUCommunity Water System(2 or more I� Building permil i51--h V 4-'06G70
connections)
❑ Individual water source(one connection), ❑ Division of land:
❑ Well #of Parcels? SPL
❑ Spdng/surfece water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please indicate name
#you he"more then one residence connected of water system below if applicable-no
to this wa#, check the PubficlCommunity Water signature required)
sysf—.box.
Part 2: Water Connection Information
Complete the section ap
propriate for the type of water connection being evaluated:
11 Public Water System....l �i 1
Name of Water System: �Q l EY4S
Water Facility Inventory(WFI)Number: EZPI�,, (write"none'for two-party)
1 am the manager of this water system.The water system has been approved for Qj_services.There
are presently connection(s)in use.This will be the—1--connection.
❑ 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 time). Please indicate on the following line the nature of
tNa charge:
This water system Is able and willing to provide water to this (these)connection(s)without exceeding the
limits of the ureter system or any limits set by state and local regulation. ,l
Print Name of Water System Manager C2 Phone -r 37S
Signature of Water System Manager Date 6�.]_(o - Z, L/
This form may be scanned and available for public view at www.MaSO"Countywa.gov
J TH Fame\Drinking Wrier
Revised 04/17/1074 Psge I of 1
Thurston County Environmental Health
20DO Lakeridge Dr.SW •Olympia,WA 98502
Txu�eozr milwar 360867-2631
COLFORM BACTERIA ANALYSIS
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