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FOR &"AtFie
r�N.F1L PA�SG� 17-1 N10s ►Z 1 tCaJbs f L S z C"ii�c Sri t suee4300,
FORM MUST BE COMPLETED IN INK f�7
PLEASE PRESS HARD PERMIT NO.; BLD �I"(
MASON COUNTY P(" /jam
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,.Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 276 446T Elma 360 482.5269 Seattle 206 464.6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner YCaNe 640".BS (!fit% Contractor Name CApS'IaNE t{oKE-5 1 NG
Mailing Address Mailing Address AD 13ok t3R
City VAL, e-f State WA, Zip Code CityA44PLE- Jh&&'Y State WA Zip Code
Phone(2S 1+32-3122-Other Ph,( Ph. 4( 25 )_t3g- t I Other Ph.(,
Lien/Title Holder Contractor Reg. # cs,kPST-M t78c"+
Address Expiration
'SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing 4=rAPtic Connect to Sewer
System n Name of Sewer System_AA-W,J Co,_WT`( Well __'Water System ?C Name of
Water System t_AcV_6LA )0 Utt.LAG1=
PARCEL INFORM TtON-12 di it Tax Parcel No. 221 C '�] Fire District
Legal Description
Site Address(Please include street name, street number and-city)
Directions to site SC_-6— if -t ML,
+� --
Will timber be cut and sold in parcel preparation? (Yes/No)_NO
Is your property within 200'of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE❑ SEASONAL RESIDENCE 0
TYPE OF JOB New Add Alt Re air Other Use of Building SF12
Describe Work
No. of Bedrooms No. of Bathrooms_2yZSQUARE FOOTAGE-1st Foor 2nd Floor
3rd Floor Loft Basement Deck Othe InCA�7b sq. ft.
Gar; ge�Attached Detached Carport Attached Detached
MOBILE HOME INFORMATION-Make Model Model Year
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price $ Replacement Unit ?(Yes/No)
Installer Name Certification No.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
.PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. ,�f /J� first o tai ' approval. .
X Date , O tom✓ X - -A
Date✓/
FOR OFFICIA USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
.................
:: •s:•.. •• f ., .. .. .,.,..;'t...;:::;:.. .. . .:,s•..•. .•???. ry.•.x
.p ............. .:.#,.:.,..,... ti:�.;,..:,sst#.^,:•>.:[•>x:;3{;.<,.^u{x
..:...
Building Department
Occ Group Type Constr.
Planning Department
Environmental Health Department
Public Works Department
A� Fire Marshal
Valuation$
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing&Base Fee 7777 Planning Review Fee
Mechanical&Base Fee Other
` _ Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
TOTAL FEES
9�j.f>O
6�
a. pTyflo-hh`u
wN
'Nm G
a
S _
-
r ,
CAPSTONE HOMES, INC.
P.O. BOX 139 --- -
MAPLE VALLEY,WA 98038
ti.
FORM MUST BE COMPLETED IN INKtJ
PLEASE PRESS HARD PERMIT NO., BLD
MASON COUNTY �)uc
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,.Shelton,WA 98584
Shelton 360 427-9670 Belfair 36Q 276-4467 Elma 360 482.6269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner STzwe f4o"z-5 (Nc, Contractor Name "OKEs 1 IVG
Majling Address Mailing Address Fb It$Ok %*q
City AAEf C-QALLCI State WA, Zip Code City.."4PLE- t1M-&:J State WA Zip Code 98038
Phone(42S)43Z-317-2-Other Ph.(_ Ph. 4t 25 ) Z- ►7t� Other Ph.(_�
Lien/Title Holder Contractor Reg. #t,=.-'E15THT(78C-A9-
Address Expiration 01 / , % / -ff-_
'SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing "rptic Connect to Sewer
System A Name of Sewer System A&M 61WN CA-1-WT`( Well_ vVater System ?C Name of
Water System L-h E-LAK)D Ut.ULAGE
Y, PARCEL INFORM TION-12 di it Tax Parcel No. z7-1 O _ Fire District
Legal Description
Site Address(Please include street name, street number and-city) tw _
Directions to siteS? —
Will timber be cut and sold in parcel preparation? (Yes/No) NO
Is your property within 200' of the following: Body of Water(Name) IN O Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE El SEASONAL RESIDENCE 0
TYPE OF JOB New A Add Alt Repair Other Use of Building gl�
Describe Work
No. of Bedrooms No. of Bathrooms SQUARE FOOTAGE-1 st F oor 2nd Flax
3rd Floor Loft Basement Deck Othe t sq. ft.
Garage_,&�Attached Detached Carport Attached Detached
MOBILE HOME INFORMATION-Make Model Model Year
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price $ Replacement Unit ?(Yes/No)
Installer Name Certification No.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
.PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the Slate of Washington and that I am aware of the ordinance
requirements for which this permit Is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith, No changes shall be made without
approval. first o tall approval.
X Date/(/� X Date+,A 0
�&
FOR OFFIblAr USE BEYOND THIS POINT
t
Accepted by bate Submittal Amount Due Receipt No.
Building Dep rtm nt
Occ Group V Type Constr. IUD -
Planning Department L.,Iq� nvdg, e 0 S
Environmental Health Department ot
Public Works Department
Fire Marshal
Valuation$
Building Permit Fee 1,51 To :
Site Inspection
Plan Review Fee `�a:� 8EH Review Fee
Plumbing&Base Fee ,� Planning Review Fee
Mechanical&Base Fee 3.� /tf ,-L6 Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
TOTAL FEES
i
6
FORM MUST BE COMPLETED IN INK PERMIT NO.:
PLEASE PRESS HARD MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 27.9670 Belfair 390 275-446T Elma 360 2.5269 Seattle 206 4"-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner tiCAES tOc, Contractor Naive k4c-5 ( G-
Mailing Address Mailing Address
City Stafe GvA Zip Code CftyA4tf[.EtJ44fi9Y Shfie WA Zip Code
Phoneme 492'3lZZOtherPh.( Ph.(42-S )432t: 01WPh.( )
Lien/Title Holder Contractor Reg.# }:YAP STH z'1?9G4
Address Expiration
SEPTIC INFORMATION-Connect to New Septic Existing Septic Conn,-l'?to Sewer System Name of
Sewer System AAk`PN cdowl`(
PARCEL INFOR ATION-12 di it Tax Parcel No. Z21 V0 00 k-J _Fire District
Legal Description
Site Address(Please include street name, street number and city)
Directions to site !!�Zec—6nrAsztif:f�
Is your property within 200'of the following: Body of Water(Name) NO Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff "stream Slopes or
Bluffs
TYPE OF JOB New_ Add Alt Repair Other Use of Buildin,
Location of Fixtures/Units 1st Floor 2nd Floor Basement C rage Closet
PLUMBING FIXTURES(Show Number of each) AL UNITS fu?al\Type: Electric
Type of Fixture No. of Fixtures Fees I-FG tural Gas _2()�eatpump
Toilets v Type $,_ �Units Fees
Bath Basins v Furnace 4-
Bath Tubs Heatpumps
Showers Vent Fans
'�qE I
Water Heater t Propane Tank
Laundry Wsher ( Gas Oyy�ts
Sinks Woore at/Peliet Stove Giro r-rd�
Dishwasher Dire ent?
Other�dt I Other
Other 11� Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK 1S BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is Issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtainin app I.
X Date 0 X
Date
FOR OFFICIAL USE BEYOND THIS POINT \�
Accepted by Date Submittal Amount Due Receipt No.
ROOM
7planning
ent
Group T Constr.
ent
Other
Permit Fee Site Inspection
i Plan Review Fee UFC Phan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal
Violation Fee TOTAL FEES
i
FORM MUST BE COMPLETED IN INK PERMIT NO�.: BLD
—"`�V
PLEASE PRESS HARD ('
MASON COUNTY
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner `7CaN& (�fD��S ��� Contractor Name C Af,5TaNE ttoM I iVG
Mailing Address__J Mailing Address PO 13ok lam]
City 1M_ft 0AUC S State WA,, Zip Code City AAAr Le QkLtri l State vJA Zip Code—R,9038
Phone(42S)43,Z-3 fZZOther Ph.(_� Ph. 4( 25 ) 't 32-31Z2 Other Ph.(
Lien/Title Holder Contractor Reg. # C_W15THT
Address 1 Expiration 01 / / 0 f._
SEPTICIWATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer
System A Name of Sewer System a&4 Ao C ;._W `( Well Water System ?C Name of
Water System O U l L.LA C-E
PARCEL INFORM TION-12 di it Tax Parcel No. 1221 00 Fire District
Legal Description
Site Address(Please include street name, street number and'clty)
Directions to site CiC"Iff—A-1160LMN
Will timber be cut and sold in parcel preparation? (Yes/No) NO
Is your property within 200' of the following: Body of Water(Name) N O Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
PERMANENT RESIDENCE 0 SEASONAL RESIDENCE D
[No.
OF JOB New Add Alt �Re�air Other Useof BuildingFbe Work
Bedrooms No. of BathroomRE FOOTAGE-1 st F oor 2nd Floor
oor Loft Basement Deck Other� 1-7.b sq. ft.
e—Attached Detached Carport Attached Detached
MOBILE HOME INFORMATION-Make Model Model Year
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price $ Replacement Unit ?(Yes/No)
Installer Name Certification No.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit Is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. ZO-4
/J� first o tai • approval.X Date�* X Date��
FOR OFFICIA USE BEYOND THIS POINT
Accepted by bate Submittal Amount Due Receipt No.
{� (��n j!y�!1�•��}�•� f;�'r'�'1•�}•.�iL"i�:;.<.:'`%:':;::::i;::;'f:.;',<:;2.`:2:v:T
v ..;;•:v4.3>t. .♦�.{1 .�•j�:{ ... y�.'.l�.]!/�. ,::•..p::%{{{y: :.7.�•:'•: 4J:7F:LiF.u{•},.: •<:{'i:::f.':::::i.'L::is:'::Y::S::{:i:%:::::::tF�1iX1Y�;f1. 7.e.:•i.Y{;�1:?!.�.I3....n.....
PROM'*
'Ak� ..},.. ..}..
Building Department Ito
_o`�-�
f Occ GroupType Constr. �J
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
'i
Valuation$
Buildi"Permit Site InspectionPlan EH Review Fee
777
'I Plumbing&Base Fee Planning Review Fee
Mechanical&Base Fee Other OCR
1 Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal ( )
TOTAL FEES
I
FORM MUST BE COMPLETED IN INK PERMIT NO.:
PLEASE PRESS HARD MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar/P.O.Box 196,Shelton,WA 98684
Shelton 60 27-9670 Beifair 360 27"67 Elma 360 2.6269 Seattle 206 464.6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner t-k*teS tN0— Contractor Name � " ( G
Mailing Address Mailing Address 3
RS
City State d& Zip Code City,uA A LlACiET�'Y State WA Zip Code 48 30
Phone 492-SkZ7-Other Ph.(_)__ Ph•(4ZS )h32-3iL20ther Ph.(
Lien/Title Holder Contractor Reg.# CA-P 1;11+s t79d;;q
Address Expiration_ ab _
SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of
Sewer System /Vqc5PN CdkA Wr*
PARCEL INFOR ATION-12 di it Tax Parcel No. 17-*2-1 1VJ5CVJ Fire District
Legal Description
Site Address(Please include street name, street number and city)
Directions to site
Is your property within 200'of the following: Body of Water(Name) NO Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
[Locatio.nof
OF JOB New S Add Alt Repair Other Use of Building
Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Type of Fixture No. of Fixtures Fees LPG Natural Gas_,6 _Heatpump
y
Toilets De of Unit No. of Units Fees
Furnace
Bath Basins _l—
Bath Tubs Venn Fans e
Showers Vent F Fans
Water Heater t Propane Tank
Laundry Wsher ( Gas Oyy�is�
Sinks Woodi(Ga (Pellet Stove
Dishwasher Dire 'G/ent?
Other Other
Other Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
---
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor In the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall
b nine inX capponformance therewith. No changes shall be made without
approval. % first
2*L_
X Date
Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
.X
Building Department
Occ Grow) Type Constr.
Planning Department
1 Other
V,• Other
N .,.
Permit Fee a Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other
' Mechanical&Base Fee other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal
Violation Fee TOTAL FEES
95a�o
S
APPROVED
MASON COUNTY DCD MANNING.
SITE PAN REQU12Ep TO BE ON SITE
-
.CHA /G/ESSSSUf3IECT TO APPROVA
BY �►d---- Date
v
6uWN6r
77
�Om
I t;.
fir-- ,• -' I
- .
o�'.4-4
Aid
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s
CAPSTONE HOMES, INC. -'
`P.O. BOX 139
�i MAPLE VALLEY,WA 98038
t.
Kill
Fr) lp
Request. To Revise An Approved Plan
Permit Number: BLD200 d0 'o Name
Parcel Number phone Num. er aa. l�ne ) �"
Project Address �/p �i �- Mailing Address '�d
11,E V Wr--.Y I ALP-°I— r
Please provide a complete,detailed description of the proposed revisions to the approved plans: .
132 WCXJD FEW
Are two sets of the revised plans or addendum indicating the changes included? Yes ❑ No
Are the approved site plans included? Yes )(No
Are the.revisions clearly and accurately identified on the plans or addendum? 0 o Yes ❑ No
❑ Yes
Does the plan contain an engineer's or architect's lateral or vertical anal
Ysis? No
If Yes,Has the engineer or architect approved this revision? ❑ Yes .❑ No
Is a stamped and signed approval included with this request? ❑ Yes ❑ No
jNote:No atn,cnn chanaes to a"desi¢ned"elan will be ay�r9ved without the written om t of the and/or arced ogremed.
Does the po ro sec revisio
P n modify the footprint or location of the structure? ❑.Yes
o
If Yes,Is a revised site plan,-with all new setback dimensions included with this request?
❑ Yes ❑ No
Additional Information:_ 3 --
i
Applicant's signature Date:
Office Use only
Reoetvred hY
Date sew Assured To Approved By pate.
Valuation: $N
l ^ — �' Additional Valuation: $
t Sq.Ft. f .g x$ / . 4e $
Sq.Ft. x S $
Total New Valuation $
Additional Fees:
Additional Planning Dept,. $
New Setbacks: Front / Rear / Additional Plan Review.
Additional Building Per`tn'it $
SWe1, / S1de2 / Additional Plumbing $
Ad 'tional Conditions/Comments: Additional Mechanical $
Additional E.H.Dept. $
Other $
o2.p
D q?. 9�' cL(,o �' Total Amount Due: $
Amount To Be Paid Up-Front$
Ted-WL!
RevbW SW W2Z1 3
�s�r
MASON COUNTY
DEPARTMENT OF HEATH SERVICES
Environmental Health Personal H�alrh
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4469
Application for Determination of Adequacy
Instructions
Ntl ye,Kex.Ha.WFKi>N4N�' VA ri'�3
ewe
Y
s u a dace e'er
� ! , .eewo-,eewsO.xaY
PART 1: Applicant/Parcel Identification
Name of Applicant HOAt5E-5► INC- Date
Mailing Address (3 )e t 3 Telephone 25-432 3 2Z
AAA-?LC- .� q�038
Assessor's Parcel Number l Z2i 7S�Q o0 23
Type of Water System Check Ong): Reasvn orA lka&n Check One :
Public/Community Water System(2 or more Building permit
connections) o Land use application,if so..
❑ Individual water source(ow connection),if so.. o Division of land
❑ Well #of parcels?
❑ Spring/surface water SPH9 -
�� o Other(explain) ❑ Boundary line adjustment
'! ❑ Other(explain)
I
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water kstem
Name of Water System
Water Facility Inventory(WFI)Number:
i
. o The water purveyor has tiled a letter granting blanket hookups to this water system.
a I am the manager of this water : The water system has been approved for servlces. 'Chem are
presently coanectio»a in use. This will be the connection. m sys is able Or and
wi ing to pproviilce water to this(these)connections wt out exeeeding the limits of tha wst�system or aay
i
limits set by state and local regulation.
Signature of Water System Mana I LJ Date
Ha YEIWA
WDATAURCHITERAD3.WP Update.Much 22,1999
W - 7