HomeMy WebLinkAboutWAT2021-00182 - WAT Application - 5/11/2021 MASON COUNTY
COMMUNITY SERVICES
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415 N 60'Street&dg 8,Shelton WA 98584. `
Straiten:(360)427-9670 ext 400 O eeyeir.(360)2754467 ext 400 o Elms:(360)482-5260 ad 400
FAX (360)427-7787
Application for Determination of Adequacy
Instructions
4 Complete Part 1 No d•lertninebon can be made until • tl• _ -
2: Complete only the portion of Pan 2 applying to the type ofx?utrayatem'd191Fad.
3, Submit win letada Iication calm.aitachmenis to the heattlyde arlmentforr`avlew.
Part 1: Applicant!0P�a��r�c�e�l Identification
Name on Applicant:rrge)a _ njiml1 Date: 1 402.1
Mailing Address: 'Pb 7jQbjR1.11—t!'i�Cj Phone: _�3fQf f -D/LtD
Parcel Number:: 14O t 'S; - O 0:1 __
Type of Water System Reason for Application
PubiUCommunHy,Water System(2 or more Building permit
connections) ❑ Division of Land-
0 Individual water source(one connecion), #of Parcels?_ SPIL
❑ Well ❑ Boundary line adjustment
❑ Spdng/surmcewater ❑ Other(explain)
❑ Other(explain)
❑ Replacement(please indicate name of water
a you have more than one residence connected system below if applicable-no signalise
to thts•retl,check the Publir9Communify Wafer required) ppRpL
System box. VE
Part 2: Water System Information ; 2 )�I)
Complete the section appropriate for the type of water system being evaluated: '0uNiYtNVjx0Nh:4TA:NFA0'
1 Public Water System - t
Name of Water System: C 6111RI rrw4 X4# 4t5 W&er 1.x�=gpanr�A
Water Facility lnventory(WFI)Number: 781,78 -1 (wine"none Mrtwo-party)
❑ 1 am me manager of this wafer system.The water system has been approved forservices.
There are presently connection(s)In use.This will be the connection,
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1"- I am the manager of this system.This connection will be W upgrade or change the use of an existing -
connection on this system(i.e.-recreglffonal to full time).Please indicate on the following line the nature
mthis change:15u,W&q 017Y ,1
This water system Is able and filling to provide water to this(these)connection(s)without exceeding the
limits of the water system or any limits eel by stale and local regulation.
i
Print Name of Water System Manager Phone 3Yzk-67-73
Signature of Water System Manager Dale
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This form may be scanned and available for public vim on the Masan County Web site.
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Printed from Mason County I