HomeMy WebLinkAboutBLD2007-01401 Cancelled SFR - BLD Permit / Conditions - 3/2/2007 w
Inspection Line(360)427-7262
4 MASON COUNTY DEPT. OF COMMUINITY DEVELOPMENT Phone: (360)427-9670,ext.352
T
Mason County Bldg. III 426 W. Cedar P.O. Box 186
Shelton,WA 98584
RESIDENTIAL BUILDING PERMIT BLD2007-01401
OWNER: MATTHEW& SARAH FINNIGAN RECEIVED: 8/3/2007
CONTRACTOR: AA&E INC. LICENSE: AAEINGC136DC EXP: 3/1/2008 ISSUED: 10/5/2007
SITE ADDRESS: 150 NE LAKE DR TAHUYA EXPIRES: 4/5/2008
PARCEL NUMBER: 223305000172
LEGAL DESCRIPTION: HAVEN LAKE S 27/238 TR. 172
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
New SFR aven Lake
General Information Construction &Occupancy f ation Square Footage Information
No. of Bedrooms: 3 Type of C tr VB
Type of Use: SF Insp.Area: No. of Bathrooms: 3 Occ. Gr -3U Lot Size: Deck: 516
Type of Work: NEW Fire Dist.: 2 No.of Stories: 3 Occ. Loa Building:3,044 Garage-Attached 680
Valuation: Building Height: 34 Occ. Status:�,2asonal Basement:1,410 COVPORCH 336
Manufactured Home Information Setback Information Shoreline&Planning Information
Make: Length: Ft. Front: 94.0 Ft. Shoreline: 50.0 Ft. Water Body: Haven Lake
SEPA?: No
Side 1:
5.0.0 Ft.
Model: Width: Ft. Rear: 5 Ft. Slope: Ft. Shoreline Desig.: Rural
Year: Serial No.: Side 2: 5.0 Ft. Comp. Plan Desig.: Rural
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty. Type Qty. Type By Date Amount Receipt
Dishwasher 1 Exhaust Hood 1 Plan Check Fee KKK 8/3/2007 $1,282.94 S22007000
Hosebibs 3 Furnace<100K 1 Planning Review Fee KKK 8/3/2007 $170.00 S22007000
Kitchen Sink 1 Gas Outlets 5 Address Fee BLF 8/10/2007 $154.00 S12007000
Laundry Tray 1 Propane Tank 1 EH Plan Review TW 8/30/2007 $75.00 §i2bb7o00
Lavatories 5 Ventilation Fan 4 Building State Fee ARC 9/13/2007 $4.50 s bbo 000
Showers 1 Woodstove 2 Additional Plan Check Fee ARC 10/1/2007 $128.00 S12007000
Water Closets (Toilets) 3 Dryer Vent 1 Building Permit Fee ARC 10/1/2007 $1,934.55 S12007000
Water Heaters 1 Mechanical Fee ARC 10/1/2007 $248.00 Si2bb7bb0
Bath Tubs 1 Mechanical Base Fee ARC 10/1/2007 $25.30 S12007000
Clothes Washer 1 Plumbing Fee ARC 10/1/2007 $121.00 S12007000
Plumbing Base Fee ARC 10/1/2007 $22.00 S12007000
ADJUST—Plan Check Fee ARC 10/1/2007 -$25.48 S12007000
Total $4,139.81
BLD2007-01401 Please referto the following pages for conditions of this permit. 1 of 5
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O Date By Z
o) Footings J Setbacks Ribbons
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o Interior Date By interior-Date By Date By D
o Extensor Date By Exterior-Date By Sot-up
Point Load/isolated Footings INSULATION Date By
BG!SLAB INSULATION D
Date By Data By FIRE DEPARTMENT �
Foundation Walla Floors Date E3y =
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Date By Data By DECKS
FRAMING Wails Date By Q°
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Date By Data ay' PROPANETANKS D
PLUMBING Vault Date 8y� X
-- ___-_ ...— _ _
Date °y'e.. OTHER
Groundwork Attic
Data By Date BV Type-
Date B y
D.W.v DRYWALL Type:
Int.Brace Wall Date By W
Date By Date By FINAL INSPECTION 0
v Water Line Fire Separation hi
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Date By Date By Dato By p
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Mason County Dept. of Community Development
Mason County Bldg. 3
426 W. Cedar
P.O. Box 186 (360) 427-9670 Local (360) 482-5269 Elma
pr
Shelton, WA 98584 (360) 275-4467 Belfair
Notice to Obtain Final Inspection
October 27, 2008
MATTHEW & S FINNIGAN
12636 SE 60TH ST
BELLVUE WA 98006
Case No.: BLD2007-01401
Parcel No.: 223305000172
Proiect Description: New SFR
The Mason County Department of Community Development is currently reviewing all
permits that are expired and have not been approved for occupancy and use.
Pursuant to Mason County Code, Title 14 Building and Construction, a permit and
final inspection for this type of activity is required under the 2006 International
Building Code or the code your permit was issued and your property is currently in
violation status of occupancy and use.
Please contact our office to make the necessary arrangements 21 days from
the date of this letter. Failure to contact our office to make the necessary scheduled
inspections will result in enforcement actions.
To bring your site into compliance, you must schedule an inspection. One (1) $68.00
site investigation fee will need to be paid prior to inspection along with any
outstanding fees currently due on your building permit. For every inspection required
after that, you will be charged $68.00 again, per inspection until final inspection and
conditions are met.
To schedule an inspection, please call (360) 427-9670 ext. 262.
If you should have any questions regarding this notification, please contact me at
(360) 427-9670 ext 595.
r
Sincerely, '
Rich Todd Balderston
Mason County Department of Community Development
Cc: Property File
October 27, 2008 BLD2007-01401
Matthew P. Finnigan
12636 SE 60th Street . Bellevue . WA . 98006 T 425/643.3861
December 12, 2008 C)c�-330 S-0 0017 �-
Rich Todd Balderston
Mason County Department of Community Development
Mason County Building 3
P.O. Box 186
Shelton, WA 98584
Dear Mr. Balderston:
Pursuant to our conversation this morning concerning Case No:
BLD2007-01401, I have enclosed a copy of my letter dated September
25, 2008 that was addressed to the attention of Phyllis. As
mentioned, we discussed this letter in our conversation of November
7, 2008 when I called to respond to your letter of October 27, 2008.
Based on our conversation of today, it is my understanding that you
have extended the above referenced permit for 6 months from today's
date. Should this information be incorrect, please advise me
accordingly otherwise I will proceed with the knowledge that the
permit has been extended as aforementioned.
Very truly yours;
Matthew P. Finnigan TO RE KEPT IN TH
-,ARCEL FILE
LE
encl:
RECEIVED RECEIV`
.DEC 15 20
42�
426 W: CEDAR ST.
Matthew P. Finnigan
12636 SE 60th Street . Bellevue . WA • 98006 T/F 425/643.3861
September 25, 2008
Mason County Building Department
Attn: Phyllis
426 West Cedar
P.O. Box 186
Shelton, WA 985W
Dear Phyllis:
The purpose of my letter is to request an extension on my building
permit. The permit number is BLD2007-01401.
We hope to start construction in the spring after completing some
revisions to the original plan, which will of course be submitted to the
Building Department for review and approval prior to beginning work.
Thank you for your attention to this matter.
Very truly yours,
Matthew P. Finnigan
Cc: Rick Chesmore, Chesmore/Buck Architecture
MASON COUNTY PERMIT NO. IS
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
On the web www.co.mason.wa.us 12C
APPLICANT INFO MA ION _ _ \` CONTRACTOR lNF0FkMAT11QN
ING
Owner I 1C Company Name
Mailing Address �� Mailing Address O -73c�
City E State Zip Code `��� City V_ State Zi{��Cod
Pho Col ''��1 Other Ph. Phon 1— Other;
Lien/Title Holder Contractor Reg. # ) a C.�1�CaE��? 1c:
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well Water System Name of Water System
PARCEL INFORMATION-12 Digit Parcel No 0 oao Fire District
Legal Description 'S A 17 3 - �- C>7'
Site Address(Please include street name,st eet number and city)We I ca L_PaG '* p- !r7*
Directions to situ
Will timber be cut and sold in parcel preparation?Ye /
Is property within 200'of Saltwater Lake_River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%X
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye o
TYPE OF JOB- New Add Alt Repair Other PRIMARY E IDENCE SEASONAL
Use of Building Et91' C-'F Describe ork
No. of Bedrooms 15 No. of Bathrooms 7Pl Square Footage- 1 st Floor C.07Cn 2nd Floor 4
3rd Floor Basement Deck"(-4 Covered Deck 7-7-421(A_Other Sq.ft.
Garage ���' Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - ake Model Year
Length Wi Serial No. N Bedrooms N Bathrooms
Type of Hea Pur a Price$ Replacement Unit? /No
Installer Name Certification No.
OWNER/BULDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Aclnowiedgement of
such is by signature ow.I declare that I m the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit anRf
do a application.,)declare that I have obtained the permission from all the necessary parties.If permission is
required f t holder an other party in interest regarding this application or the work proposed in the application,I have obtained
permissiom to for s ft and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is a rants pi of Mason County access to the above described property and structure for review and inspection.
PROOF OF N O K IS BY MEANS OF A PROGRESS INSPECTION r
Date:
Owner/Owners Re re entative/Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee - Site Inspection
Plan Review Fee AL, EH Review Fee
Plumbing& Base Fee Planning Review Fee
Mechanical&Base fee Other
Wood/Gas/Pellet Stove Fee State Fee Z/-i
Violation Fee /IGO eAE r- Pre-Paid at Submittal
Valuation$ ZLZ TOTAL FEES
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PERMIT NO.
MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W. Cedar• P.O. Box 186,Shelton,WA 98584
Shelton(360)427-F7p•Belfair((360)275-4467•Elma(360)482-5269
On the we wtlrw.co.mason.wa.us
LICANT INFORMATION CONTRACTOR I F M TIO
lner M v V�A\C,3 Company Name
Mailing Address 1 4eE Coo Mailing Address ='
Cit tate Zip Code"V?2S=K=Q' C. 'F'111 State Zi oc�e
Ph' C-1 'S Other Ph. Ph 'y "Z a Other 2 �'
Lien/Title Holder Contractor Reg.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC INFORMATION - Connect to New SepticX Existing Septic^,. Connect to Sewer System
Name of Sewer System
PARCEL INFOR ATIQN 12 Di it Parcel No o5��'Q Fire District
Legal Description VV & 7K 'b 72 --!a7 "Z =
Site Address(Please include street namevstreet number and city) l� =fL
Directions to site ���- Aa T" 11-lc>
Is property within 200'of Saltwater Lak River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%
TYPE OF JOB -New Add _/Slt Repair Other Use of Building
Location of Fixtures/Units- 1st Floor.&— 2nd Floor Basement Gara a Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL U!ELPG—NaturW
S
ape of Fixture N f ')t Fees Fuel Type:Electdc Gas Heat Pump_
Toilets Tyne of Unit No.of.UnitsFees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank
�lothes Washer 1 Gas Outlets
ithen Sinks Wood/Gas/PelletStove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other 5t 1V._ Other
Gjtiav Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do work as propo in the application.I declare that I have obtained the permission from all the necessary parties.If permission is
required from y s nt hold r or y other party in interest regarding this application or the work proposed in the application,I have obtained
permission fr ern ply f th' rmit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is to g ern yees of Mason County access to the above described property and structure for review and inspection.
PRO Ti AT N ORK IS BY MEANS OF A PROGRESS INSPECTION. & 2
Date: �
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group—Type Constr.
Planning Department
Environmental Health Department
FEES
rbin & Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/ Pellet Stove Fee Other
Violation Fee TOTAL FEES
PERMIT NO.
MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W. Cedar•P.O. Box 186,Shelton,WA 98584 3^�
Shelton(360)427-gg67 •Belfair((360)275-4467•Elma(360)482-5269
On the we wvlrw.co.mason.wa.us
T
LICAyT INF AT ON I \ \,� Company Name IN 4Fi;MATIOf�
Mailing Addres 1 '� Mail,' g Address �� 1�.1�p
City 4 tate Zip Code fk`bcR Co C��2 State Z o52
Ph C�1 'S Other Ph. P Other - ` ��
Lien/Title Holder Contractor Reg.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC INFORMATION-Connect to New SepticK Existing Septic. Connect to Sewer System
Name of Sewer System
PARCEL INFOFI ATION 12 Digit Parcel No o'S Q Fire District
Legal Description �YlLxlE 10�> 4!P -72 V-"Pr—"<;s7~2--�
Site Address(Please include street name itstreet number and city)
Directions to site ��'�- Aa A"? D
Is property within 200'of Saltwater Lak River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 150%
TYPE OF JOB -New Add Alt Repair Other Use of Building
Location of Fixtures/Units- 1st Floo _ 2nd Floor Basement Garage Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UN.IJS
lype of Fixture No.of ixtures Fees Fuel Type:Electdc LPG_Natural Gas Heat Pump_
Toilets (III Type of Unit No.of Units Fees
Bathroom Sink It 111 Furnace LPG
t Hea um
Bath Tubs tp s p
Showers I Spot Vent Fan 4-
Water Heater Propane Tank
Pothes Washer Gas Outlets Foo- S•so
nithen Sinks as/Pellet Stove 11
Dishwasher f0tchen Exhaust Hood
Hosebibs Dryer Vent
Other 54�v. Other
"'54w- Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
01NNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do work as propo �inr the application.I declare that 1 have obtained the permission from all the necessary parties.If permission is
required from y s ntho roother party in interest regarding this application or the work proposed in the application,I have obtained
permission fr ern ply th' mit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is c ate g ern yees of Mason County access to the above described property and structure for review and inspection.
PRO TI AT N ORK IS BY MEANS OF A PROGRESS INSPECTION. & 2
Date: �
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bid Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group-Type Constr.
Planning Department
Environmental Health Department
FEES
Jbinq & Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/ Pellet Stove Fee Other
Violation Fee TOTAL FEES
Look Up a Contractor,Electrician or Plumber License Detail Page 1 of 2
Washington State Department of Labor and Industries
General/Specialty Contractor
A business registered as a construction contractor with L&I to perform
construction work within the scope of its specialty.A General or Specialty
construction Contractor must maintain a surety bond or assignment of
account and carry general liability insurance.
License Information
License AAEINGC136DK
Licensee Name A A&E INC GENERAL CONTRS
Licensee Type CONSTRUCTION CONTRACTOR
UBI 601011607
Ind.Ins.Account Id
Business Type CORPORATION
Address 1 PO BOX 730
Address 2
City BELFAIR
County MASON
State WA
Zip 98528
Phone 3602754006
Status ACTIVE
Specialty 1 GENERAL
Specialty 2 UNUSED
Effective Date 3/12/1987
Expiration Date 3/1/2008
Suspend Date
Separation Date
Parent Company
Previous License
Next License
Associated License
Business Owner Information
Name Role Effective Date Expiration Date
VANDIJK,JOHN 01/01/1980
VANDIJK,DEBBIE 01/01/1980
JENSON,PAUL S AGENT 01/01/1980
Bond Information
Bond
Bond Company Account Effective Expiration Cancel Impaired Bond Received
Bond Name Number Date Date Date Date Amount Date
Until
#8 CBIC SF0935 08/05/2003 Cancelled $12,000.00 08/05/2003
https://fortress.wa.gov/lni/bbip/printer.aspx?License=AAEINGC 136DK 10/1/2007
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MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
August 10, 2007 PO BOX 1666 Shelton WA 98584
Shelton (360)427-9670
Fax (360)427-8442
MATTHEW & S FINNIGAN Elma (360)482-5269
12636 SE 60TH ST
BELLVUE WA 98006 Belfair (360)275-4467
Case No.: BLD2007-01401 Parcel No.:223305000172
Dear Applicant:
Your building permit cannot be approved by Mason County Environmental Health until
the following are completed and turned in:
Please see comments at the end of this letter.
Please call me at(360)427-9670, ext. 554 if you have any questions.
Sincerely,
Trish Woolett
j tw@co.mason.wa.us
Environmental Health
Mason County Health Services
Comments: NEED NEW SITE PLAN SHOWING NEW SYSTEM AND OLD
SYSTEM NOT BEING USED.
E
i
8/10/2007 1 of 1 BLD2007-01401
Request To Revise An'Approved Plan
Permit Number: BLD200_Z- CzJ4-c-1 Name -J�Vp S��
Parcel Number 2Z--t�'5 Q6:B, 9=1=1c=>r7Z Phone Number daytime ce=>2-7-14.*7
Project Address F-- i 9-vco Mailing Address
WA `� .irZ o
Please provide a complete, detailed description of the proposed revisions to the approved plans:
Are two sets of the revised plans or addendum indicating the changes included? Yes ❑ No
Are the approved site plans included? R"Yes ❑ No
Are the revisions clearly and accurately identified on the plans or addendum? ❑ Yes/ ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? Yes ❑ No
If Yes,Has the engineer or architect approved this revision? -eyes ❑ No
Is a stamped and signed approval included with this request? Yes ❑ No
(Note:No structural changes to a"designed"plan will be approved without the written consent of the engineer and/or architect of record.)
Does the proposed revision modify the footprint or location of the structure? ❑ Yes X'-No
If Yes, Is a revised site plan,with all new setback dimensions included with this request?
❑ Yes ❑ No
I
Additional formation:
Applicant's signatur 1 Date: "7
4
Office Use Only Received by:
ate Sent Assigned To Approved By Date
Original Valuation: $
❑ B. / 7Additional Valuation: $
ElP / Sq.Ft. x$ $
Sq.Ft. x$ $
❑ Total New Valuation $
Additional Fees:
❑ L4 Additional Planning Dept. $
Additional Plan Review $ ,
Additional Vndations/Comments: Additional Building Permit $
9:Zd Additional Plumbing $
--z Od 2'S Additional Mechanical $
Additional E.H.Dept. $
Other $
I
Total Amount Due: $
Amount To Be Paid Up-Front$
THIS PARCEL
INCLUDES
PLANS, BLUEPRINTS
OR OVERSIZE
IMAGES
LARGE FORMAT
IMAGES HAVE BEEN STORED IN
FILE CABINEf(S) UNDER
PARCEL NUMBER
PARCEL # J2,A3D
CASE # 8L0 a00�- 0140/
Mason County Planning Intake Checklist
Owners Name: l yk') Date: b
Project: Reviewed By:
Commercial Develop . YES Comments:
PLANNER: GBM TS C PBC RDH REC
Site Plan:
North Arrow
o Property Dimensions: X
Li
and Driveways Shown. Road name: IL h
All Existing Structures shown with setbacks
Well Location, Septic and Drain-field Shown WkLsetbacks
Identify all surface water (streams, ponds,(tre n , wetlands, natural or historic drainage,
defined drainage ditches)
*-,Topography (slopes)
Proposed Structure S tb cks (Direction/Setback): S
F: _� R: —J 1: J S2:
Utility and Drainage Easements: Yes No (if yes enter condition #5022)
Other Easements
Accessory Appurtena Pro pa ���Zv-OV �� S
Variance applied for: Ye o - parking spaces allotted? Yes / No
County Access Permit Needed ((add condition #0010) �QI� ( ,,
State Access Permit Needed (add condition #0020) C)
Standard Conditions to be added to all Building permits that planning reviews: #5019 and #0700
Site Access: Are there any impediments (dogs/gates) that my restrict access to your site?
Is the site clearly marked? How? Address � d
❑ Name
Critical Areas: ❑ Other:
Setbacks: Shoreline: �' Slope: N( -
Shoreline Designation: Comprehensive Plan: Rpral Zoning:
❑ Not Applicable ❑ Agricultural RR 2.5/ 5J 10 20
Urban ❑ In-holding ❑ RMF v
Rural ❑ LTCFL ❑ RC 1 2 3
❑ Conservancy \$10 Rural ❑ RI
❑ Natural ❑ RAC ❑ RNR
❑ Unknown ❑ RCC-Hamlet ❑ RT
❑ Urban Growth Area ❑ MPR
❑ Unknown ❑ Unknown
Water Body (type o r if unnamed):
SEPA: Yes/ No tknow Flood Plain: YES/NO nknown Map#
Aquifer Recharge: YES/NO LkknovyA Map#
Tags/Cases- �
RLC/SPI Case: M, D(v tz na4o 6-Year Dev. Moratorium: YEM/N
Eagle Nest Tag: YE e Other YE
Revised: 07-10-2007
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AN
Jul 11 07 03:20p Matthew Finnigan 425-378-1199 p.1
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Envir�nmenta!Health - Personal Health
PO BOX 1686 SHELTON.WA 985U
LOCAL(360)427-9670
AIR(360)2757
Application for Determination of Adequacy OELFFAX(360)427-7798
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully cor—mleted.
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: ApplicandPa cel Identification
Name of Applicant 167; ' 7 !e/ ° '7
Mailing Address I_z6 36 .Sri �cf Sir Pr f(e;A6 ��G
Telephone �Zs �y 3 3 J3 E
Assessor's Parcel Number 4tQ0 2z3 TO 5-0 ( ?L cS -ZZ33o �j 7
T of Water S stem Check One): Reason for lication (Check-one).,
o P6111dCommunity Water System(2 or more Building permit
�nO"e� O Land use application,if so..
Individual water source(one connection), o Division of land:
if so..
#of Parcels? SPL
ffg/surface water ❑ Boundary one adjustment
❑ Other(explain) ❑ Other(explain)
"If you have Mrs than one residence ❑ Replacement(please indicate name of weber system
connected to this well,check the Public box. below if applicable-no signature i
�9 required) I
I
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 Fac1ity Inventory(WFI) Number.
(write"none"for two party)
17 1 am the manager of this water system.The water system has been approved for_T l
There-are presently connections)in use. will be the services.
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 natwe 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
tom:April zoos
s