HomeMy WebLinkAboutWAT2024-00285 - WAT Application - 10/2/2024 Ue
MASON COUNTY WAT
COMMUNITY DEVELOPMENT
Tmn bu+Yr'[e!arre.n...e
415 N 6" Street,Bwg 8.SheBon WA 98584,
Shellon (060)427-9670 ext 400 4 Seaar(360)275�e#400 O Ehna (�)482-5269 e t 400
FAX(J60)427-7797
Application for Determination of Water Adequacy
Instructions
1. Complete Pan 1. No determination can be made until Pan t a fully competed.
2 Complete only the portion of Pan 2 applying to the type of water connection utilized.
3. SubmN completed appitcahon,with any required attachments for review
4. An appmved building site plan must acczmpanj this application
Part 1: Applicantf Parcel Identification
Mnrtc I t strtM Date
Name on Applicant: �i ti in �s &eKc>Vv%
Mailing Address: t Ir3 0 T,,- row T.ks IN Phone. 3J0 -&33-12r8S
Parcel Number. to to C2
Type of Water System Reason for Application
Pubec/Communny Water System(2 or more a Building pernd T0✓-D-Z4-o0 t 3
connections) ❑ Division of land:
❑ Individual water source(one connection). N of Parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spdng/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below 6 applicable-no
to Mrs well, check the Pubhc Communify Water signature required)
System box C
Part 2: Water Connection Information t3 0 62yL
Complete the section appropriate forthe type of water connection being evaluated: f,•.. -SITU'
rn�L4T '
Public Water System
Name of Water System: 1 `r✓°�nO(` t:opnyni t7 LIHb
Water Faahly,Inventory(WFI)Number 89HOo V
(write-none'for two-party)
❑ 1 am the manager of this water system.The water system has been approved for—Sefv"S.
There are presently wrinection(5)in use. This will be the connection. I
■ 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.: recrealiohal to toll ame). Poease indicate on the following line the nature
ofthischange: Lo7 {,A1 ek�5t n� w�tr. $erv• (e
This water system Is able and willing to provide water to this (these)connection(s)without exceeding
the limas of the water system of any limits Set b stale and Wcal regulation.
Signature of Water System Manager �__—
DateZy
This form may be scanned and available for public view at w=LCJMA2MXW&
RNisal 1.Z12019
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