HomeMy WebLinkAboutWAT2025-00127 - WAT Application - 6/18/2025 WAT 2025-00 t2'1
.r1117 ;,: MASON COUNTY
'k COMMUNITY SERVICES
-�` RECEIVED
ir-,r Budding.Planning.Envvonmemal Health Community Health
415 N 61h Street. Bldg 8. Shelton WA 98584, 11�����1,�
Shelton:(360)427-9670 ext 400 8elfair:(360)275-4467 ext 400 •: Elma:(360)482-52pUNt 498 2025
FAX(360)427-7787
Application for Determination of Water Adequa415 W. Alder Street
Instructions _
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
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 Identification
Name on Applicant:;'JVt.i�T11 IC46,,-I 1440e' Date' '` 11- ZS —
Mailing Address: S/ it,V 4.tn/ye Po1f1_, 1 t1D 'I U7 Phone: 7017-c-6 - _ :{S
Parcel Number: 1 _7-� \ � 10�t,i .__.
Type of Water System Reason for Application
4 Public/Community Water System (2 or more `l Building permit
connections) 0 Division of land:
O Individual water source(one connection). ft of Parcels? SPL
O Well 0 Boundary line adjustment
O Spring/surface water 0 Other(explain) _
O 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. APPROVED
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated: JUL 1 4 2025
Public Water System MASON COUNTY ENVIRONMENTAL HEALTH
RET
Name of Water System: t R?
Water Facility Inventory(WFI)Number: f- 2-79
(write"none-for two-party)
11. I am the manager of this water system. The water system has been approved for L services.
There are presently <U connection(s)in use. This will be the \ connection.
0 I am the manager of this system. This connection will be to upgrade or change the use of an exis'ng
connection on this system (i.e.: recreational to full time). Please indicate on tile 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.otAr) -7
Signature of Water System Manager Date �' ! J /S
This form may be scanned and available for public view at www.co.mason.wa.uS.
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