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ORBS .. TO F <br />KITTITAS COUNTY <br />DEPARTMENT OF PUBLIC WORKS <br />Ti►St:DLfTTY -.� <br />WATER NIITIGATION CERTIFICATE APPLICATION <br />Application for: 0 Mitigation Package A $47075.00 Payment Method: 0 Check _ <br />0 Mitigation Package B $4,990.00 0 Cash <br />0 Card <br />Owner Name: <br />Mailing Address: <br />Phone Number: <br />Email Address: <br />Applicant Name: <br />Mailing Address: <br />Phone Number: <br />Email Address: <br />Project Specific Parcel Information <br />Assessor's Parcel #: Map #: <br />Situs Address: <br />Legal description of property (attach additional sheets as necessary): <br />Project Information <br />Proposed project description: <br />Is the well part of a public water system? 0 Yes ❑No <br />If Yes, Name of Public Water System: <br />Is the well part of a shared well? ❑ Yes ❑No <br />If YES, parcel# where well is located: <br />Permit # <br />Date Stamp <br />Please choose one of the fallawine: <br />❑ My well was drilled before December 2, 2015 <br />17 My well was drilled after December 2, 2015 <br />0 No well has been drilled <br />Kittitas County Water Mitigation Application Page i of 5 <br />411 N. Ruby St- Suite i TEL (509) 962-7523 <br />Ellensburg, WA 98926 FAX (509) 962-7663 <br />