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Health A OATER FACILITIES INVENTORY (11
Environmental Health Read Instructions on back before completing
���ClSl7�tJih et�n/°2-
TEM ID NO: 2.,y�{COUNTY GROUP TYPE WR WFI COMPLETED
�BY TITLE
lk=r �V\ d /.✓ N`IS !AI
5. SY NAME DAY TELEPHONE DATE
ADDITIONAL ROUTING INFO- 8. SUBMITTED NEW SYSTEM; NO CHANGE REACTIVATE
FOR
SYSTEM NAME CHANGE* HUPDATE DELETE
MAILING ADORESS *OLD SYSTEM NAME-ENTER ONLY IF CHANGING WITH THIS WFI
• f o $tom
CITY STATE 21P CODE RESIDENTSSYSTEMS SERVING ANY (PEOPLE
4wainew Wh _CJ!9544, DWELLING SERVED BY THE SYSTEM),COMPLETE THIS SECTION
4. OWNERS NAME(LAST,FIRST) S. NUMBER ACTIVE RESIDENTIAL 10.NUMBER ACTIVE RESIDENTIAL
{ fT0OUNG,_�•� , fir ? CONNECTIONS POPULATION
ADDITIONAL ROUTING INFO t �( ri 1
(f D
MAILING ADDRESS
NON-RESIDENTSSYSTEMS SERVING ANY
po EMPLOYEES,STUDENTS,ETC.),COMPLETE THIS SECTION
CITY STATE ZIP CODE 11.NUMBER NON-RESIDENTIAL CONNECTIONS
6aAftVIeVJ WPC -9f,5 M
5. SYSTEM CONTACT PERSON TITLE
12.ENTER AVERAGE DAILY NON-RESIDENTIAL POPULATION
y jG1'kLaG1 C4�tSt&j.�_ SERVED FOR EACH MONTH.MAKE ENTRY FOR EACH MONTH
DAY�DTELEPHONE G L EVENING TELEPHONE 101 a s JULY
MAY(CHECK ONE ONLY) (CHECK ONE ONLY)
6 OWNERSHIP 7 PREDOMINANT CHARACTERISTIC MAR
1&DOES THE SYSTEM SERVE AT LEAST 25 OF THE SAME NON-RESIDENTS
FOR 4 OR MORE DAYS PER WEEK FOR AT LEAST 180 DAYS PER YEAR?
TPF4VATE:
VATE:NON-PROFIT RESIDENTIAL
FOR-PROFIT RECREATIONAL YES �NO
ALGOVERNMENT SUSINESS/1NDUSTRIAL/
( UNTY/CITY/PUD/ AGRICULTURAL/COMMERCIAL.
WATER D►STRICT) LODGING/FOOD SERVICE 14.TOTAL NUMBER IS.DISTRIBUTION RESERVOIR(S)
CONNECTIONS METERED TOTAL CAPACITY
STATE SCHOOL/DAY CARE
R FEDERAL OTHER(CHURCHES,ETC.) GALLONS
18.SOURCE 24.SOURCE LOCATION
.•
CATEGORY
o .
UST UTLITY'S NAME FOR SOURCE.
IF SOURCE IS PURCHASED OR a w ¢
(NTERTIED,LIST SELLER'S IDS z Q o + _o (FEET) (RPM) 1/4,i/4 SEC. TWP RNG.
AND NAME USING FOLLOWING w N W a ' c+_a SEC. NO.
FORMAT:XXXXXX/NAME a ca w _ a 0. ~
wzZ U gM II 0:�6
EXAMPLE:77050V/SEATTLE 3 3 Z �R Ie O
WeL4- I X X 273 NW ZI tw
MINIMUM REQUIRED BACTERIOLOGICAL SAMPLING SCHEDULE
25. 26. JAN FEB MAR ` ' APR MAY JUN JUL AUG SEP OCT NOV DEC
J
APPROVED SERVICES(PER PLANS) ' DATE OF LAST SANITARY SURVEY BY DOH LHD
YSTEM IN CRITICAL WATER SUPPLY SERVICE AREA? YES NO GW MGMT AREA? YES NO FOFl.UiD
USE ONLY
EFFECTIVE DATE RETRO.CHANGES SIGNATURE OF DOH REVIEWER DATE
DOH 331-011(Rev.3/99) DEPARTMENT OF HEALTH
Y.1 , `
8 S u d WATER FACILITIES INVENTORY (WFI) '
��1J�ealth ��
i'Environmental Health Read Instructions on back before completing
STEM ID NO. 112. COUNTY GROUP TYPE WRIA WFI AOMPLETED BY TITLE
3. SYSTEM NAME DAY TELEPHONE uy DATE
ADDITIONAL ROUTING 8. SUBMITTED NEW SYSTEM NO CHANGE REACTIVATE
FOR
SYSTEM NAME CHANGE' UPDATE DELETE
MAIUNGADDRESS OLD SYSTEM NAME-ENTER'ONLY IF CHANGING WITH THIS WFI
CITY STATE ZIP CODE SYSTEMS SERVING ANY RESIDENTS (PEOPLE
(3l:*,,',('*ff:'r,7 k,I U 1W V1 I A 9 k':1 6 DWELLING SERVED BY THE SYSTEM),COMPLETE THIS SECTION
4. OWNERS NAME(LAST,FIRST) OWNER NO. 9. NUMBER ACTIVE RESIDENTIAL 10.NUMBER ACTIVE RESIDENTIAL
I CONNECTIONS POPULATION
1 t r::>t.11( jE:1 �.1•v.i I=''h .. ��' ':.�.,i .1.1:11'! z...<:•:?i.�'�
ADDITIONAL ROUTING INFO 0
MAILING ADDRESS SYSTEMS SERVING ANY NON-RESIDENTS
PC) BOX EMPLOYEES,STUDENTS.ETC.),COMPLETE THIS SECTION
CITY STATE ZIP CODE 11`.NUMBER NON-RESIDENTIAL CONNECTIONS
01F'.(1('il(. y/ to )rq c�e:}xr.
.,�Y i? ,I
5. SYSTEM CONTACT PERSON TITLE 12.ENTER AVERAGE DAILY NON-RESIDENTIAL POPULATION
SERVED FOR EACH MONTH.MAKE ENTRY FOR EACH MONTH
DAYTELEPHONE EVENING TELEPHONE JAR JULY
ry `(pp.. ..
..F 'J )`.. +'i,..4f�(:J•»} .t...}t,.i....RY�,7 ...1 is„j,.1.�. MAY �. NOV.
all
OWNERSHIP 7. PREDOMINANTMAR. SEP.
(CHECK ONE ONLY) (CHECK ONE ONLY)
13.DOES THE SY TEM SERVE AT LEAST 25 OF THE SAME NON-RESIDENTS
FOR 4 OR MORE DAYS PER WEEK FOR AT LEAST 180 DAYS PER YEAR?
PRIVATE:NON-PROFIT RESIDENTIAL
PRIVATE:FOR-PROFIT RECREATIONAL El YES iC, NO
v BUSINESSANDUSTRIAL/
LOCAL GOVERNMENT AGRICULTURAL/COMMERCIAL
(COUNTY/CITY/PUD/
WATER DISTRICT) LODGING/FOOD SERVICE 14. TOTAL NUMBER 15.DISTRIBUTION RESERVOIR(S)
CONNECTIONS METERED TOTAL CAPACITY
STATE SCHOOL/DAY CARE
8 FEDERAL OTHER(CHURCHES,ETC.)
GALLONS
16.DOH 1
SOURCE SOURCE NAME 18.SOURCE 24.SOURCE LOCATION
CATEGORY
NUMBER
W.
LIST UTILITY'S NAME FOR SOURCE. ~
w
IF SOURCE IS PURCHASED OR cal w ¢ z
INTERTIED,LIST SELLER'S ID# z F > w o (FEET) (GPM) 1/4,1/4 SEC. TWP PING.
AND NAME USING FOLLOWING W W m ,y! w a z Z o SEC. NO.
FORMAT:XXXXXX/NAME LL a w = d a o cWi ¢a ¢ rc -
J LL z Z ¢ U N N ¢ ¢ W ¢ W
EXAMPLE:.77050Y/SEATTLE ¢ ¢ z +�,+ ¢ ¢ ¢a _ F
<', 1' 1'!M", r.t;: i`
MINIMUM REQUIRED:.
25,' 26. 1 JAN FEB I;MAR APR MAY JUN JUL AUG SEP
APPROVED SERVICES(PER PLANS) DATE OF LAST SANITARY SURVEY BY DOH LHD
YSTEMIN CRITICAL WATER SUPPLY SERVICE AREA? YES NO GW MGMT AREA? YES NO FOR ONLY
USE ONLY
EFFECTIVE DATE RETRO.CHANGES SIGNATURE OF DOH REVIEWER DATE
i
i
t
DOH 331-011(Rev.3/99) WATER SVGTEM
i
8t5e« m� WATER FACILITIES INVENTORY (WFI) UIP—DATED
t W Health .
Environmental Health Read Instructions on back before completing
DATE UPDATED: 0:2 11,
STEM ID NO. 2. COUNTY GROUP TYPE WRIA WFI COMPLETED BY TITLE
071055 ASON 14
3.SYSTEM NAME DAY TELEPHONE DATE
MASON CO FIRE: PROTECTION D I ST: 3
ADDITIONAL ROUTING INFO S. SUBMITTED NEW SYSTEM NO CHANGE REACTIVATE
FOR
SYSTEM NAME CHANGE': UPDATE ' DELETE
MAILING ADDRESg 'OLD SYSTEM NAME-ENTER ONLY IF CHANGING WITH THIS WFI
PO BOX 129
CITY STATE ZIP CODE (PEOPLESYSTEMS SERVING
CRAPEV I EW WA 98546 DWELLING SERVED B COMPLETE SECTION
4. OWNERS NAME(LAST,FIRST) OWNER NO. 9, NUMBER TINE RESIDENTIAL 10.NUMBER ACTIVE RESIDENTIAL
POPULATION
MASON GO FIRE PROTECT ION 2U,E39
ADDITIONAL ROUTING INFO 0
MAILING ADDRESSTRAVELERS,
PC) BOX 129EMPLOYEES, COMPLETE SECTION
Crty STATE ZIP CODE 11.NUMBER NON-RESIDENTIAL CONNECTIONS
GRAPEV I EW WA 98546 1
S.SYSTEM CONTACT PERSON TITLE 12.ENTER AVERAGE DAILY NON-RESIDENTIAL POPULATION
STAN CATRON MGR SERVED FOR EACH MONTH.MAKE ENTRY FOR EACH MONTH
DAY TELEPHONE EVENING TELEPHONE JAa �' `
.e
.' ,q NOV .
360- 275-�4'48� 360-275-6251. :.. ,. MAY �
PREDOMINANT MAR.
OWNERSHIP 10
� � �.,.� ., SEP +` ;
ONE• ONE ONLY)
73.DOES THE SYSTEM SERVE AT LEAST 25 OF THE SAME NON-RESIDENTS
FOR 4 OR MORE DAYS PER WEEK FOR AT LEAST 180 DAYS PER YEAR?
TPRtVATE:
VATE:NON-PROFIT RESIDENTIAL
FOR-PROFIT RECREATIONAL ED YES a NO
ALGOVERNMENT BUSINESSINDUSTRIAL/
( UNTY!CITY/EN / AGRICULTURAL/COMMERCIAL
WATER DISTRICT) LODGING I FOOD SERVICE 14. TOTAL NUMBER 15. DISTRIBUTION RESERVOIR(S)
CONNECTIONS METERED TOTAL CAPACITY
RSTATE SCHOOL/DAY CARE
FEDERAL �' OTHER(CHURCHES,ETC.) GALLONS
16.DOH 17.SOURCE NAME i a.SOURCE 24.SOURCE LOCATION
SOURCE ••
NUMBER z
LIST UTILITY'S NAME FOR SOURCE r °w
IF SOURCE IS PURCHASED OR w
INTERTIED,LIST SELLER'SIDr� z > ° o (FEET) (GPM) 1/4,1/4 SEC. TWP RNG.
AND NAME USING FOLLOWING w w w w¢ z o a SEC. NO.
FORMAT:XXXXXX/NAME a z w = a 0 0 a
EXAMPLE:77050Y/SEATTLE w�u¢ z w¢ ¢a z= F
'S01 WELL. #1 X � x '7` NE/NW 00 21N D i 4
MINIMUM REQUIRED BACTERIOLOGICAL SAMPLING SCHEDULE
25. 26. JAN FEB MAR APR MAY " JUN JUL AUG SEP OCT NOV DEC
ONCE A YEAf2
APPROVED SERVICES(PER PLANS) 0 DATE OF LAST SANITARY SURVEY BY DOH LHD
LHD
YSTEM IN CRITICAL WATER SUPPLY SERVICE AREA? YES NO GW MGMT AREA? YES NO FOR ONLY
USE ONLY
EFFECTIVE DATE RETRO.CHANGES SIGNATURE OF DOH REVIEWER DATE
DOH 331-011(Rev.3/99) LOCAL HEALTH