HomeMy WebLinkAboutWAT2026-00085 - WAT Application - 4/13/2026 WAT 2026 00085
COUNTY
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A0006 tiatn tot bot rnilnatIon of W itur Adequacy
Instruc n
I Complete Pert I. No determination can be"made until Part 1 is fu fly completedp
2 Complete only The portion of Part 2 applying to the typo of water connection utilized .
Submit completed appilchtlan with;any,required alteatbinezils for review
.: . . MepproadbuHdtngetteplan.must ccoitt ati ,cilia-a' flcaflon..,..,
__ --pair 1 can a"rcel�i�[ iitificatib� __ . . ..
iVaitte of Appliant: (Jc rk. Date: ,3 6 y- •2t�Z
ParcelNumber. ?2i72" 50 00LIZ, t
Type of Water System Reason for Application
Public/Community Water System(2 or more Building permit
connections) ❑ Divlsion of land:
.0 Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary tine adjustment
0 Spring/surface water ❑ Other(explatn)
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.
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Part 2: Water Connection Information
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Complete the section appropriate for the type of water connection being evaluated: EH APPROVED
Public Water System Rhonda Thompson 05/1512026
Name of Water System:L A k-e Lgiggr &tc f c 4 �r $y≤ vv
Water Facility Inventory(WFI)Number: 111.1150" (write°none' for two-party)
❑ lam the manager of this water system.The water system has been approved for services.There
are presently connection(s)in use.This will,be the________connection.
Rlam the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system .e.:recreational to full time).Please indicate on the following line the nature of
this change b
This water systemisable and wIlflng to provide water to this(these)connection(s)without exceeding the
limits of the water system or any limits stet by state and local regulation.
Print Name of Water System Manager_ fS' 6� (J1ui le n Phone 3r____ ____
Signature of Water System Manager 1/ IL[ Date q_;3...
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This form may be scanned and available for public view at www.masoncountywa.gov
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