Loading...
HomeMy WebLinkAboutWAT2024-00399 - WAT Application - 9/23/2024 WAT 7 Qp R % 415 N.6°Street -- Status,WA 99594 MASON COUNTY Shelton-360427-9670,sxl.400 COMMUNITY SERVICES Bv�.36"Z�9?,es"xt`4o pdSMPWmI^9EnrMwniwulXeelU�CamonlM1He+IXi Application for Determination of Water Adequacy Instructions Part 1. Complete Part 7. No determination can be l the type of water oonnectiontufilaed. 2. Complete only the portion of Part 2 apply' g 3. Submit completed application,with any required attachments for review. 4. An approved building site. Ian must accom an this a -'-cation. Part 1: Applicant/Parcel Identification 09/23/2024 Name on Applicant: Alan Olson Date. 707_290.0693 Mailing Address: 1192a 54rd Ave SE Everett.WA.9a409 Phone: 16-3�— Parcel Number: 42216-53-00035 Division-block-lot: Type of Water System Reason for Application ❑ Building Permit Id Public/Community Water System(2 or more ❑ Division of land: connections) #of Parcels?-- SPL ❑ Individual water source(one connection), ❑ Boundary line adjustment ❑ Well Placement of Park-Model onto property ❑ Spring/surface water © Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name Of water system below if applicable-no If you have more than one resident&connected signature required) to this well, check the PubGcrCommunily Water System box. APPROVED Part 2: Water Connection Information DEC i 2 2024 Complete the section appropriate for the type of water connection being evaluated: Public Water System ISASONCOUNTYENVIROHMENTALHEALTH Name of water system: LAKE CUSHMAN SYSTEM 5 RET Water Facility inventory Number: 035290 (veite"nonaF Tor two-party) ❑ I am the manager of this water system.The water system has been approved for'a�e rvirss.There are presently connections)in use.This will be the connection. I am the manager of this system.This connecgon will be to upgrede or change the use of an existing connection on this system(Le,:recreational to full time).Please indicate on the following line the nature of this change: W P de Motlal ohs D DDM 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. Print Name of Water System Manager JESSE MATHEWS Phone 360-877-9668 H+awr osns/zoza Signature of Water System Manager=—"— Date This fore,may be scanned and available for public view at••W ^o mason wa.us. Revised 4I27=1 1: 11FormsluJ nkingW�r