HomeMy WebLinkAboutWAT2024-00320 - WAT Application - 9/12/2024 WAT7fw
MASON COUNTY 415 N.6-S..
Shelaa WA M"
Public Health & Human Services Ma :W2iimeT:eat.4M
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 kidding site plan most accompany this application.
Part 1: Applicant/Parcel Identification "
Name on Applicant eXaD4s /4<~H /ir Data: 9/L/Lt,,
MaMng Address: ,G�X 7m 3"s—
Parcel Number: 222z/- S2- aG173/ TFBC Lot#
Type of Water System Reason for Application /.
PubliclCommunity Water System(2 or more ❑Building pemsa�i cll Za2A _010q I
connections) ❑ Division of land;
❑ Individual water source(one connection), #of Parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spnngtsudace water ❑ Other("Plain)
❑ Other(explain)
' ❑ Replacement or Remodel(please indicate name
If you hate more Man one residence connected of water system below 0 applicable—ne
to this well,check the Public/Communily Water signature required)
System box. A
Part 2: Water Connection Information l'PR
Complete We section appropriate for the type of water connection being evaluated: OCT O VEt)
Public Water System 44SONCO 08 1p1
Name of water System: Twanoh Falls Beach Club ONMfNTq
Water Facility Inventory(WFI)Number. DON#WA 107510 (write'rarie'for two-party) Rcr N�ITN
❑ lam the manager of this water system.The water system has been approved for services.Thera
are presently connection(s)in use.This will be the_correction.
>(-I am the manager of this system.This correction wtll be to upgrade or charge the use o1 an existing
connection on this system(Le.:recreational to tug lima).Please indicate on the following line the nature of
this change: r�VL T\N(L 21L1t 6
1Z: J T%/1[_
This water system Is able and willing to provide water to this(these)connedlon(s)without exceeding the
limits of the water system or any limits set by stale and local regulation.
Print Name of Water System Manager Scott Gordon FBC Water Daectolshone360,731-2233
Signahae d Water System Manages' Date 0I — I- 12-2tj
This form may be scanned and available for public vlew at vrww.maeoncoun VeiMw
I iwnn Dnntim way It—...1.122o]a Paid o!2
.4CMIwtl wah i
®CamSo....