HomeMy WebLinkAboutBLD2007-00612 - BLD Water Adequacy - 4/12/2007 MASON COUNTY
DEPARTMENT OF HEALTH 5ERVIC-E5
Environmental Health Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360) 275-4467
Application for Determination of Adequacy FAX(360)427-7798
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 system utilized.
3. Submit completed application,with attachments to the health department for review.
PART 1: Applicant/Parcel Identification
Name of Applicant Z, Date
Mailing Address L2�c L&Ife-LIAL i,,�3 eleph on e 366-3 Z2-,9 2'206-
14
Assessor's Parcel Number 2,3 r1l;2 Z-�-Z 7 Z
T_ype of Water System (Check One):. -Reason for Application (Check One):
Public/Community Water System (2 or more Building permit
connections)- Ll Land use application, if so..
• Individual water source(one connection), 0 Division of land:
if so..
Well #of Parcels? SPL
Spring/surface water o Boundary line adjustment
• Other(explain)---- o Other(explain)________________
**If you have more than one residence Li Replacement(please indicate name of water system
connected to this well, check the Public box. below if applicable-no signature required)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System
Water Facility Inventory (WFI) Number:
(write"none"for two party)
❑ I am 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.
❑ 1 am the manager of this system. This connection will be to upgrade or change the use of an
existing connection on this system(ie:recreational to full time). Please indicate on the 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.
Signature of Water System Manager Date
Update:April 2006