HomeMy WebLinkAboutWAT2024-00383 - WAT Application - 2/4/2024 ` wAT� 003 3
MASON COUNTY
COMMUNITY SERVICES
9uJJln4 PWnNp"FmlranmxRd Hweh cammivahHrdn
415 N 6z Sheet.Bldg 8,Shehon WA 98584.
Streaon:(360)427-9670 ext 400 O Betteir(6))755-4467 04 400 O Etna:(360)482,289 ext 400
427-7787
Application for Determination of Water Adequacy
Instructions ,
1 Complete Pad 1 No dbtBunindt den ha.ipaoe uhtil Part t is co
2. -ComRlete onlyifhe porNon.a Pad apptyingiathe type 0f wN er P, tilt Igast
3. $ubmn camper appYkars,witE1 anp required ailechmefits for ravi :, s.
4 '. An" 'roved 3dllltlin airs: -n must
Part 1: Applicant/ Parcel Identification
Nameon Applicant -Md Cke iSTPNf a Oate:
Mailing Address: V''t'S N' SXf ,-I-Alit ref none: Z+1 G32... 7 Z7'b
Parcel Number: j 2-3 O 9—3 µ _��03 ` w+• ISM S'
Type of Water System Reason for Application
K PubliclCommunity,Water System(2 or more Building permit
connections) ❑ Division of land:
❑ Individual water source(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 mole than one residence connected of water system below If applicable-no
to t we#, check the PubliNCommunify Water signature mquigpd��
System box. /--�, ROVED
Part2: Water Connection Information y�� MAR 03 2025
Complete the section appropriate for the type of water connection being evalu.W.0N COUNTYE.ViRONMENTAL HEALTH
Public Water System RET
Name of water System: Spares-�.
Water Facility Inventory(WFI)Number: t 83 G
(write none'for two party)
JK I am the manager of this water system.The water system has been approved for 6-, services.
There are presently ?-- connection(s) in use. This will be the_T 1 connection,
❑ 1 am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time). Please Indicate on the following line the nature
of this change:
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.
Signature of Water System Manager " Date 2-;"q-/Z +S
This form maybe scanned and available for public view at www ro mason.wa.us.
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