HomeMy WebLinkAboutWAT2025-00032 - WAT Application - 2/18/2025 MASON COUNTY wAT
COMMUNITY SERVICES
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415 N 6^Street.Bldg%Shelton WA 98584,
Shelton:(360)427-9670 ext 400 0 BeNFr�(36i)2754467 787d 400 O Elms:(360)4825269 ext 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 rs full 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. Ana roved buildingsite Ian must aocom an this a lication.
Part 1: Applicant/ Parcel Identification
Name onAppgcant:CF-?AV-Y' U1I1CrA_Date: fl!g11-��ry� `�'S
Mailing Address: ' 1^,,tt Phone: I K A 'Rog L
Parcel Number:a'.-g(��`� Ph �� 11�1 � -"'sMeJtC
TypaWater 517sfejnt �Oe 3 1 Reason for Application qn
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PubliriCommunity Water System(2 or more gl Building permit �I'd 262,5j - W I I (,e
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Springisurface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please Indicate name
If you have more than one residence connected of water system below 9 applicable—no
to this well, check the PublWCommunity Water signature required)
System box. APPROVED
Part 2: Water Connection Information MAR 12 2025
Complete the section appropriate for the type of water connection being evaluated:MASON COUNTY ENVIRONMENTAL HEALTH
Public Water System
Name of Water System: lnl 4 f "-Il ^y G
ILA
Water Facility Inventory(WFI)Number. G7�37U
/(write"none'for two-party)
1
v I am the manager of tthisyyy�ter system.The water system has been ap�Loyed for/Ruo services.
There are presently connection(s)in use.This will be the 'SO 6 connection.
❑ I 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 One 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 li se by st to a d Date and local regulation. ''tt
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Signature of Water System Manager
This form may be scanned and available for public view at•••••-+co mason.wa us.
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