HomeMy WebLinkAboutWAT - WAT Application - 4/24/2025 r
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WAT 1'
40.___
MASON COUNTY e\s-4 atSN haStrbel
Sitdton,WA 9RM
Public Health fit Human Services I(A\ Stwiftm:3Mt 427.967f).Ku acx►
Fklrair 160•27S_1467.F.xk arx,
Application for Determination of Water Adequacy
Instf actions
1: Complete Part 1. No determination can-be made until Part i is fully completed.
2 Complete only the portion of Pact 2 applying to the type of water connection utilized.
3 Submit completed application with any required attachments for review.
4. An appt oved building sitepten must accompany this application.
Part 1: Applicant!Parcel Identification
Name of Applicent: {..0✓...141 Ar,$-144,2e.__...__ Date VY4.40.2!""
Melling Address: 5:ev t 4cor Rd tom• e `s"e`" Phone: 3(.0-V 61171.i
Parcel Number: 123 ,2c 4'2 o 0020 ,2� 5044 r Qv-�1 3�
Type of Water System Reason for Application
11PubtictCommunity Water System(2 or more 0 Building permit
connections) 0 Division of land:
❑ lndvidual water source(one connection), 1 of Parcels? SPi_.
O Wel 0 Boundary tine a nt
❑ SpringNwrfece water 13 Other(explain) __Ti•
® Other(explain) 0 Replacement or Remodel(please indcate name
it you have more than one residence connected of water system below if applicable--no
to this welt check the Public/Community Water signature required)
System box.
Part 2: Water Connection Information
I Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: ( e Pe r GJIi, I' LI.LS''i'r
Water Facility Inventory(WFI)Number: pS 3 5-0_ (write'none'for two-party)
0 1 apt the manager of this water system.The water system hes been approved for services.There
rare presently _._connections)In use.This will be the connection.
id 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;letxeational to full time).Please indicate on the following line the nature of
this change: C<e•,o v 1.+sW
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 end local regulation.
Print Name of Water System Manager„ink." G 1 Phone ;40 aZ74iai S
Signature of Water System Manager 4_,,..- .t1 —s Date I/A y/46-
This form may be scanned and available for public view et www,tttasoncountywa.00v
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