HomeMy WebLinkAboutWAT2024-00323 - WAT Application - 9/16/2024 • WAT�-•L-��Z
MASON COUNTY
COMMUNITY DEVELOPMENT
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415 N 6e Street,Bldg 6,Shellon WA 98584.
Shelton (360)427-9670 ext 400 t- Belf 75-4677 ext 400 d Elms (360)482-5269 ext 400
FAx(360)
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 roved buildin site Ian must accom an this a licelnn.
Part 1: Applicant!Parcel Identification
Name an Applicant Aschlee&Jacob Heiny Date: �1- I to-2 A
7550 Phone: 36063a�4
Mailing Address:
Parcel Number. 12220-54.OW43
Type of Water System Reason for Application
II( PublicJCommunity Water System(2 or more I$ Building permit Uid20-Z,4•Di I I Jr
connections) ❑ Division of lane.
❑ Individual watersource(one connection), #of Parcels?_ SPL
❑ 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 below if applicable—no
to this well, check the Public/Community Wafer signature required)
System box. APPROVED
Part 2: Water Connection Information OCT 08 2024
Complete the section appropriate for the type of water connection being eval"i COUNTY ENVIRONMENTAL HEALTH
Public Water System
Fwnneton
e of Wafer System:
r Facility Inventory(WFI)Number.
wme-none'for two
Q'7
am the manager of t - water system The water system has been apprpvgQ for /!5services.
here are presently connecuon(s)in use.This will be the c connection.
it be to
ade or
ge
he use of an
I am the onager of on this system this system,
(ge.nrecrea anal t This o full time)Please indicate on hetfollow following line the existing
nature
of this change'.
This water system is able and willing to provide water to this(these)connection(S)without exceeding
he limits of the water system or an k set by ate and local regulation.
Signature of Water System Manager y Date
This form may be scanned and available for public view at Www co.mason wa,us.
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