HomeMy WebLinkAboutWAT2024-00279 - WAT Application - 7/8/2024 415MOS6eet
A 98594
MASON COUNTY SM. stwltagwat400
COMMUNITY SERVICES Belffi`'�'2546'a,FxL400
Bdae 360AII 4n 7,En.400
EIsu:360-0SL5269,EiL 400
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.
I Submit Completed application,with any required attachments for review.
4. An approved building she plan must sccomp2ny this application.
Part 1: Applicant/Parcel Identification A/� Z
Name on Applicant: �liy_1�nna�Q Dale: 1,Q_ .3- Z� O'6aDa
Mailing Address: y f�J/ Kf Ai/f 3/D Phone:
Parcel Number% 31W 1-50 't����
Type of Water System Reason for Application
II7 Public/Community Water System(2 a more �' Building permit t�L tF;O 4 0
005(oo,
/ connections) ❑ Division of land:
❑ Individual water source(one connection), g of Parcels? SPi.
❑ Well ❑ Boundsry line adjustment
❑ Spdng/surfaW water ❑ other(explain)
❑ other(explain) ❑ Replacement or Remodel(please Indicate name
tryout have more than one rasidence connected of water system below if applicable—no
to Nis wall, check the PubiwCommunify water signature required)
System box. APPROVED
Part 2: Water Connection Information OCT O
Complete the section appropriate for the type of water Connection being evakuded: 8 2024
Public water System MASON COUNTY ENVIRONMENTAL HEALTH
Name of Water System: Madrona Park
Water Facility ln,mtpry(WFI)Number 057933
(wdte'none'for two-party)
❑ 1 am the manager of this water system.The water system has been approved for 7the
—/There are presently conneclion(s)in use.This will be the conney I am the manager of this syatom.This connection will be to upgrade or change the uConnection on this system(1.e.:recreational to full 6me).Please indicate on the follow
of this change: I naCtlVe to Active Connection
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 yk( ,e!^y Date n7/QR/2024
This form may be scanned and available for public view at www co m�.,�.wa us•
Rr+ cd 4IQ2018
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