Lewis County Public Health & Social Services
Environmental Services Division
2025 NE Kresky Ave, Chehalis, WA 98532 ● Phone: (360) 740-1146 ● Fax: (360) 740-1245
PUBLIC WATER AVAILABILITY NOTIFICATION
WAN #: _________________ Development Permit No.: ________________________________________
Property Location: ________________________________________________________________________
Applicant’s Name: ________________________________________________________________________
E-Mail: _________________________________________________________________________________
Applicant’s Mailing Address: ________________________________________________________________
Street City Zip
Signature of Applicant: ________________________________________ Date: ________________
APPLICANT MARK AND COMPLETE ONLY ONE: CHOICE A or B
Option 1: Two service connection water supplies
(To be completed by applicant)
Two connections (At least one a non-dwelling unit) ID# ______ Two dwellings units on separate parcels
Two dwelling units on same parcel Two dwellings units one an ADU
Proposed connection location:
Tax Parcel # _______________________________________________ Lot # ________
Short/Large/Long Plat # ______________________________________ Lot # ________
Well lo
cation, the well supplying water for this permit is located on: (check one fill in the blanks)
Tax Parcel # ________________________________________________ Lot # ________
Short/Large/Long Plat # ______________________________________ Lot # ________
Signature of Applicant: ________________________________________ Date: ________________
DEPARTMENT USE ONLY:
Yes No The shared well WS# ___________ has met the requirements of LCC8.55 and is approved to supply water to two
connections as described in this document. This approval is not a certification of the current water quality.
Signature/Title: _____________________________________________ Date: __________________
Option 2: Public/Community Water Supply (To be completed by a water system purveyor)
System Name: _
_____________________________ ID # _______________ Group A or B: ____________
Membership/Account # _____________________________
This system is capable of and will supply water to: (check one fill in the blanks)
Tax Parcel # ________________________________________ Lot or Space #
Short Plat # ________________________________________ Lot or Space #
This property is located at the address listed at the top of this page. All fees have been paid and the connection is authorized
Si
gnature/Title: ____________ Date: _______________
Note: Water Connection Approval for a public water supply is valid for only one year from date of approval below:
DEPARTMENT USE ONLY:
Yes No This public water supply is in substantial compliance with WAC 246-290 Group A or LCC8.55 Group B and is
adequate/approved to furnish water to this connection.
Signature/Title: _____________________________________________ Date: __________________
Permit Technician: ____________ Reconnection: Yes ___ No ____ Previous WAN#: __________
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