HomeMy WebLinkAboutWAT2025-00098 - WAT Application - 4/24/2025 0201p
WAT '1a 5 - 000q F I
fm, . , MASON COUNTY" 415 N.G''Street
Shelton.WA 98584
Shelton:360-427-9670,Ext.400
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" Public Health & Human Services ticifair: tea= s.:ktr, xt.aoo
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Aplicadion for Determination of Water Ade€ 9aC APR 2 4 2025
( ciiefo I CflJrteit x`i5ti ilr�
J Instructions ""
e 1. Complete Part 1. No determination can be made until Part 1 is fully completed.
_l_. 2. Complete only the portion of Part 2 applying to the type of water connection utilized.
4) 3. Submit completed application with any required attachments for review.
C. 4. An approved building site plan must accompany this application.
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c`-} Part 1: Applicant/ Parcel Identification
Date: �-� �ZS
Name of Applicant t1� (� \I� ��C Pt-ANT (.Ci .te r r`�
Mailing Address: lk n)(, \ S-'FcQ'�i S‘LQ hon6.J l 3t��) -Igo 3 r`c 1 0
Parcel Number: r,2-- 000 lc()
Type of Water System Reason for Application
� Public/Community Water System(2 or more Building permit s tit 262 00 5'7
connections) 0 Division of land:
0 Individual water source(one connection), #of Parcels? SPL
CI Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
0 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 Public/Community Water signature required)
System box.
EH APPROVED
Part 2: Water Connection Information Rhonda Thompson 06/11/2025
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: v �.��`t' V,..V\l�}0 CC'
Water Facility Inventory(WFI)Number: (write"none"for two-party)
0 I am the manager of this water system.The water system has been pproved for ,/ / services.There
are presently f�1D connection(s)in use.This will be the /,'S( 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 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 sot by state and local regulation.
` Phone60#2.74C76 X 65Z-
Print Name of Water System Manager t�� /
Signature of Water System Manager
Date dyrL`((Zo Z5
This form may be scanned and available for public view at www.masoncountvwa.Qov
):\EFI Forntsl Drinking\Vntcr
Revised 05I08R024 Page I oft