HomeMy WebLinkAboutWAT2025-00031 - WAT Application - 2/18/2025 WAT t� DD03 I
MASON COUNTY
COMMUNITY SERVICES
W MEN4 CLnn irg,Enimmenul NeJN Gmmmky aeelp
415 N 6a Street,Bldg 8,ShelW WA 98584,
Shelton:(360)427.9670 ext 400 4 Selfair:(360)2754467 ext400 O Elma:(360)4825269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made unfit P rt 1 is fully 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. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification erG p, _
Name on Applicant: (��)�ZqY��1IV�11t r�iJ✓04I Date: .2-.p /'rr0�0�' ! ��yy
Mailing Address:a 7U la iii TZ Ltyy,t. hone: �yt/t gllo� ,546 of
Parcel Number: tty`r IF Lnrt.NNegI.G
Type aeuras�. ;,, tt)A. `l$3ZD
yp j system Reason for Application
Pubic/Community Water System (2 or mi Building permit
connections) D Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spdnglsurfam water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below if applicable-no
to this well. check the PublicYCommunify Water signature required)
System box. APPROVED
Part 2: Water Connection Information MAR 1
25
Complete the section appropriate for the type of water connection beingevalu M
1AlBbNCOUNiYENVIRONMENiALNEtdi•
Public Water System R
ET
Name of Water System: VN C11,6
m Water Facility Inventory(WFI)Nuber: 9-9 370(
(write"none"for two-party) ](!�
Ill am the manager of ter system.The water system has been a yeti ford• •b services.
There are presently connection(s)in use.This wig be the_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 as by st/at/e aqd local regulation.
Signature of Water System Manager
Thle form may be scanned and available for public view at www.co.mason.wa.us.
11FJi Fwms1 prinking Wnoa Revised 1i251201 S