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HomeMy WebLinkAboutWAT2025-00086 - WAT Application - 6/17/2025 r ATr * . c ^... • -4I3:4.6 Stroot • MASON COUNTY Shelwb.VA 4804 Sh4Jta,:360.427.9690,lit.dW COMMUNITY SERVICES 1041r,360.47P4167,C.at.eu7a,knavao rmM•v .M + wapi .c«monwtH«.ih Ulna):%60-482.1269;P•x1.A00400 . Application for Datartnlllatltorf of Water Adoqunoy Instructions . 1• Complete Part 1. No detonnInat(on cut b.8 made until Pert 1 is fully contalete 2. Complete only the podion of Part 2 appty1fl to the type Of water cOhne0Uon UIHzed, 3. Submit completed sppflogticn,with any required attachments for Clow, 4. . AI.approye4 building site plan must accompany thr$appilaaUori. pad I: Applicant/Parcel rdarttlticatlon •' .' ' AFPI Date: 0`�TIS-2o2s • ..�- Name 9r!Applicant: Whale -_ Mailing Address: 420 E Rasor RdW Botteis WA98528 Phone: •(81719978875 Parcel Number. 222237790094 Type of Water System .. . • . ,Reason for Application /Pubild onenunityWater System(2 or more I Rufldfn0 Pslmk-?ie•)ZU�S- a) colmecOs) © Olvislorrof(errd: • ❑ 'Individual water source(one connectIon)1 #of Parcels?, SM., Q Wail 0 Boundary Rile adjustment ❑ Spring/surface water O Other(axplilln) • • ❑ Other(a In) epacen a If you neve mole than one re4tdence connected of water system below if applicable-no to this well,check the Public/Community Water signature required); i-- ,t f�p O`�/,E D syesir box. Pert 2: vIatJor.Conbectf�Information JUN 1 7 2025 Complete the section appropriate for the type of water connection being evaluated: MASON COUNTY ENV ONMENTAL HEALTh Public Water System ~ RET • Nem.Of Water System:• R C1 Z O r Roac{ L. Water Facility inventory&VF1)Number Oil 0 y CI X (write`none for two-party) i I pip the manager of this Water system.The water system has bean a 6 s alcoved for ervices. There ere arisen* 11 cormection(s)in us&This will be the - • connaofipn. 0 I am the manager of this system,Thla connection will be to upgrade or change the use oven rxistin9 oonrisotIOI on this sysem(i.e::recreational k fult.11me).Please indicate on the following line Pie nature -of this change: This water.y,tOm Is able and willing to provide water to this(thew)conneotfon(a)without exceedhr9 ' the limits of the water system Of any limits set by e and local regulation. ?rin Oa : Ravi re � signature of Water System Aa/ager � O eteV/6j - This form may be scanned and avatildge Mr public view etaineysmonatimtamime J: .H RI/nul lA[01Ni WE Revival 61l4/2 I