HomeMy WebLinkAboutWAT2024-00392 - WAT Application - 10/25/2024 MASON COUNTY
COMMUNITY SERVICES
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415 N 6"Street.Ship 6.Ste l WA 98584. q82-5169 ex?
Shelton (360)427.9670 ex1400 a BNfan (360)2754467 ext 400 4, Exist
(110)
FAX(360)427.7787
Application for Determination of Water Adequacy
Instructions
i
Complete Part 1. No determination can be made until Pan 1 ie fully comoleled.
Complete only the portion of Part 2 applying to Inc type of water connon w12ed.
Submit completed application.with any required e0acbments for review An approved buildin site ten must accom an this application
Put 1: Applicant/Parcel Identification
Nameem Applkant (�'L C ids{' Date: lob / 14
`1---1`'s�Twa.can t ar.o _s3]-tr199
McYklg Addreae: �ae2S= st�,s. ❑^�
j Parcel Number. 12L-�9�- y2-�l�O
Type of Water System Reason for Application � L
® Publio'Community,Water System(2 or more Building perma�letto 1_i3�
connections) ❑ Dwision of land:
❑ Individual water source(one connection). #of Parcels?_ SPL
❑ WOO ❑ Boundary line adjustment
❑ Sprmglsurface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
#you have more than one himaeno,connected of water system below if applicable-no
to this well.check the PubhCICommun#y Water signature repupdL
System box. APPROVED
Part 2: Water Connection Information BAN 2 7 2025
Complete the section appropriate for the type of water connection bung evalu'ON COUNTY ENVIRONMENTAL HEALTH
Public Water System PPT
Name of Water System: 1
Water Facility Inventory(W FI)Number:
(writs'none'for two-party) /��
`$ I am the manager of s w tars tam.The water system has been a for�7 /66rwces.
There are Pre amity conhecbon(a)in use.This will be the connection.
❑ I am the manager of this system.This connection will be to upgrade or change me use of an existing
connection on this system(1 e, recreational to full bme). Please indicate on the following line the nature
of this change:
This water system u able and willing 10 provide water to this(these)connection(s)without exceeding
the limits of me water system or any 8peit set by al a and local regulation.
Signature of Water System Manager Date 10-,6
This form maybe scanned and available for public view at y+Jyw.co.mason.wa.us,
1 Ell room 1 n6.,N'." 15R011,