HomeMy WebLinkAboutWAT2025-00055 - WAT Application - 8/6/2024 •
WAT v�C',j,'1 - Qly
MASON COUNTY 415N.0SIN:et
Shcke,WA 91451s4
Shelton.30-427.9670,Ext.400
Public Health Pt Human Services Btifair.360-275.4467,Ext.400
Application for Determination of Water Adequacy AUG 0 6 70Z4
Instructions ttichcie 3 9 ,felt x 566 UTLV
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
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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 Identificationfi_ // -
Name of Applicant: (jCo,D4,S �� � �� Date: ed.tJr/
Mailing Address: ,De. 064,Y 74 Phone: . - Zee, 33.Z5"�
Parcel Number; fix/ 1- - /•elae)
Type of Water System Reason for Application
tel5ublic/Community Water System(2 r more t3''l:;uilding permit �� 2625 - 000545
connections) 0 Division of land:
0 Individual water source(one connection), #of Parcels? SPL
0 Welt 0 Boundary line adjustment
0 Springisurface water 0 Other(explain)
1:1 Other(explain)
0 Replacement or Remodel(please indicate name
It you have more than one residence connected of water system below if applicable-no
to this well,check the Public/Community Water signature required) APPROVED
APPROVED
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated: APR 2 1 2025
Public Water System MASON COUNTY ENVIRONMENTAL HEALTh
RE I
Name of Water System:
Water Facility Inventory(WFI)Number: ?'OA Z_nI (write`none"for two-party)
AB i em the manager of pis water system.The water system has been roved for l/i�� services.There
are presently !1/,5 connection(s)in use.This will be the -/-i; connection.
0 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 lime). 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.
Print Name of Water System Manager yl;;"...,nre•41' `' S''4 f Phone 36.1W. 7- 7a
Signature of Water System Managers- -Y - Date ('es-/:.)6, Z`r�
This form may be scanned and available for public view at www.masoncountywa,gov
it It Y,nm.Drinking Wzici Iterl<cd 0'.08 2024 Ng,:I of
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