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CC -O CD CD CD n = y �• CD CD CD y CD Cy (D 3 �, C _. .. _ �rfisrrg mnrrY-wn.rrr _.. •...., IK CONCRETE MEC ANICAL MANUFACTURED HOME w Footings 1 Set acks Date It 6 d3 B yRL> Ribbons o Date fsc (� By Gas Piping Date By co Foundation alls Date 11_6 -0,3 By Set-up Date By INSULATION Date By B G I Slab Insulation Floors Final D ate B y Date B y Date B y FRAMING Walls C4-P^2e'-'1 FIRE DEPT Date By Date By Date By PLUMBING Attic OTHER Groundwork Date By Date By WALLBOARD NAILING D.W.V. Date //-/7-cam' By/`73- Date i [103 b3 By LS FINAL INSPECTION Water L' a Date — �f By �2 Date [ D3 3 B Date By ID 1462 lo3tp3 � , 0 Lvm,6 4- ?�kx y N r 2- _ �c- .,�� / �c O 0 MASON COUNTY P��'� --�' BUILDING PERMIT APPLICATION D i/ 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 APPLICANT INFORMATION ' CONTRACTOR INFORMATION Owner 1: 1 j Contractor Name lot: r:I Mailing Address w ':� Mailing Address e6t �DX -730 City A L_y))j State WA Zip Code City j-_'9GFAIYL State W&_Zip CodeCto 2 Phone (3bD > ](_ they Ph. ( ) Phone ZkO7TS- tilVDther Ph. ( ) Lien/Title Holder 014% o Contractor Reg. #AR£1N(aL I3k Mp. 94/ 2+ Email Address Email Address SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic_Se Connect to Sewer System Name of Sewer System Well.�k _Water System Name of Water System PARCEL INFORMATION - 12 digi Tax Pa cel No. 1202 2 1 _/ nOD 0 Fire District Legal Description I Site Address (Please i clude street nam , street number and city) W Directions to site W1 ` I tI `e_ CA.02LE Will timber be cut and sold in parcel preparati ? (Yes o Is property located within 200' of saltwater VM Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs PERMANENT RESIDENCE 121 SEASONAL RESIDENCE ❑ TYPE OF JOB - e '�t Add Alt Repair Other Use of Building Is this permit submittal the result of-as-top Work Notice,Correction Notice or other enforcement action?(YesU Describe Work L No. of Bedrooms 3 _ No. of Bathrooms 2_SQUARE FOOTAGE- 1 st Floor 2nd Floor 3rd Floor Loft --- Basement — Deck Pf2L2l H sq. ft. Garage Attached Detached Carport ttached Detached MANUFACTURED HOME INFORMATION -Make; Model Model Year Length Width Serial No. No. of Bedrooms No. of Bathrooms Pric $ Type of Heat PurchaseReplacement 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. OWNER/BUILDER ACKNOWLEDGES SUBMISSION OF INACCURATE INFORMATION MAY RESULT IN A STOP WORK ORDER OR PERMIT REVOCATION.ACKNOWLEDGEMENT OF SUCH IS BY SIGNATURE BELOW: OWNER AFFIDAVIT-I certify that I am exempt from the require- CONTRACTOR'S AFFIDAVIT- I certify that I am currently regis- ment of the Contractor Registration Law RCW 18.27 and am aware tered as a contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit is issued and of the ordinance requirements regulating the work for which this that all work will be done in conformance therewith. No changes permit is is d and all work shall be done in conformance there- shall be made without first obtaining approval. No a es shall be made without first obtaini"ppr X Date Date / FOR OFFICIAL USE BID THIS POINT Accepted by++ ( Planning Pd Ck# Date r 1 ,a� ( Bld Pd. /�J _ Reciept No. T t lr ,. 4. Building D ent /� J �' �23 A/F ���� i, el Occ Grou �'JT e Constr. V I�/ Planning Department 03 Environmental Health Department Public Works Department Fire Marshal Valuation$ l\O,Q,V1,�y i s gp Building Permit Fee Site Inspection Plan Review Fee 4$ EH Review Fee Plumbing&Base Fee G 00 Planning Review Fee Mechanical&Base Fe NO G(7 Other Wood/Gas/Pellet Stove Fee State Fee S Violation Fee Pre-Paid at Submittal ( ) x' TOTAL FEES 4= = PERMIT NO.: MASON COUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Ceda'r/P.O.Box 496 Shelton,WA 98584 Shelton(360)42709670 Belfair(3601�1764467 Elma(3601482-5269 APPLI NT INFORMATION CONTRACTOR INFORMATION Owner 1, )t ,�f ,^ T�{L 1�1(J Contractor Name :rlr 141 (AL 2w,.5.�?VJ T�� Mailing Address L=l 7!f � c.t kA IN �. Mailing Address City h 11,4 t, State - Zip Cdde��i7_` City t��iii State�� Zip Code Phone( rs )Z�.I.-h4 Other Ph.( ) Ph.P! 6 ) '�,� 400& Other Ph.(� Lien/Title Holder t I la+ Con ractor Reg. #e._e.E tN t-C 06 Address E iration / / SEPTIC INFORMATION-Connect to New Septic sting Septi _Connect to Sewer System Name of Sewer System PARCEL INFORMATIO - 12 digit Tax arcel No. / 7 / / 1, (�_Fire District _.Legal Description � e-- t 1 Site Address(Please AcTlude street rfar street Amber and city C7 211 16 k JJJ& y�& AJJ'-r fJ Directions to site )S 0 e `1 ti -OiAl 1-0 Is your property within 200'of the following: Body of Water(Name)k I/A Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JO ew Add Alt Repair Other Use of Building t Location of Fixt nits 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 Heatpump _ Toilets — z Type of Unit No.of Units Fees Bathroom Sink _ Furnace Bath Tubs 2.. Heatpumps 1 Showers Spot Vent Fan Water Heater I Propane Tank # Clothes Washer I Gas Outlets Kitchen Sinks 1 Wood/Gas/Pellet Stove Dishwasher ( Kitchen Exhaust Hood Hosebibs Dryer Vent I Othe Other rl/ 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-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. onformance therewith. No changes shall be made without approval. first btain' g a roval. X Date ,X Date �CIAL USE OND THIS POINT Accepted by Date Submittal Amount Due- Receipt No. Building Department Occ Group Tvpe Constr. Planning Department A Other Other Permit Fee 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 ) TOTAL FEES Violation Fee PERMIT NO.: MASON COUNTY PLUMBING/MECHANICAL PERMIT APPLICATION y � 426 W.Cedar/P.O.Box 186 Shelton,WA 98584 Shelton(360)427-9670 Belfair(360)�75-4467 Elma(360)482-5269 APPLICANT INFORMATI N CONTRACTOR INFORMATION rlL. 0Owner LAW I l Z4 Mailing Address Mailing Address Wo . F_nX MO City_N 0 State� Zip Code q# S' Cit flat L State _ Zip Code Q \ Phone��Other Ph.(_ Ph.(fk& D Other Ph.(_� Lien/Title Holder of All Contractor Reg. #AAE IN 1-C Address Expiration_/ / SEPTIC INFORMATION-Connect to New Septic qi(sting SeptJi _Connect to Sewer System Name of Sewer,System k; PARCEL INFORMATIO 12 digit Ta- x arcel No. / / Fire District i n I I VJ Legal.Descript o Ske Address(Please i clude street a e,street number and city) 2 vV Directions to site ti w 4- -� Is your property ywithin 200'of the following: Body of Water(Name) Saltwater + Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JO ew Add Alt Repair Other Use of Building's Location of Fixtu nits 1st Floor 2nd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type: Electric Iyoe of Fixture No.of Fixtures Fees LPG Natural Gas Heatpump )jJ_ Toilets Type of Unit No.of Units Fees Bathroom Sink _ Furnace 1 Bath Tubs ?,• Heatpumps I Showers Spot Vent Fan Water Heater —�— Propane Tank Clothes Washer t Gas Outlets 1 Kitchen Sinks �— Wood/Gas/Pellet Stove Dishwasher Kitchen Exhaust Hood 1 Hosebibs Dryer Vent I OtherWLAIW. t 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]]aContractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinanrequirements 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 wconformance therewith. No changes shall be made without first obtaining shall be don onformance therewith. No changes shall be made with approval. first btai ' g a roval. yj )( Date D ate dv Z FOR OFFICIAL USE OND THIS POINT Accepted by Date Submittal Amount Due Receipt No. f�RrtMEtVTAL:itl €Eaf3F:>::>::»:«:»::>:<::: :::::::AFF R(]VEQ #3:::::::::.::::::::.:::::::::......................CDhi . F3F.F Building Department Occ Group Type Constr. Planning Department Other Other ........................ Permit Fee 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 { MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT RECEIVED Planning AUG 2 8 2003 Mason County Bldg.1 411 N.5th P.O.Box 279 Shelton,WA 985M (360) 427-9670 Belfair(360) 275-4467 Elma (360) 482-526d26 W!,EM XZ* 464-6968 REQUEST FOR BUILDING PERMIT EXPEDITION NAM: 1 A LAJ QE�jCf— ��K OA J MAILING ADDRESS: I` M0 PWN � AU-10 LNA 9951+ PARCEL NUMBER: 1 ZZZ�} 3Z 000 4-0 LEGAL DESCRIPTION: /�L. jj12- N�Z N SITE ADDRESS: ("7246 jjVj I' � NA�jN WA q RS2 REQUEST DUE TO: MEDICALLY NECESSARY_ FIRE DAMAGE__ EXPLANATION OF HARDSHIP: LE l e 1M A TAU 0�z�a WE ero A �R Qrr , -5QM t L4 1S `ZT J I P Lr W H-k EL I ME> . M4 -O'JAWI W qNs libg A Qf-,-Cf--m LU u1, :I psA -r .t' &(2w M'> wl-f-VI CAI AXIS-INCE - U V I NU 10 714ftr2- OWL) QoUt o 6-geaj�j ttLP NA CCU yR2- ::FeDVA T�C Y�WL (0A510f-12A7WA , MUST INCLUDE SUPPORTING DOCUMENTS THIS MAY BE A. LETTER FROM A DOCTOR INSURANCE CLAIM REPORT OR REPORT OF FIRE DAMAGE FROM APPROPRIATE FIRE REPRESENTATIVE . I (WE) UNDERSTAND THE INTENTION OF THIS FORM IS TO DETERMINE AND DOCUMENT JUSTIFICATION FOR EDITION OF A BUILDING PERMIT TO ALTER OR RECONSTRUCT A RE D C THE ABOVE D PROPERTY. SIGNATURE OWNER AG i OFFICIAL USE ONLY REQUEST DENIED FOR FOLLOWING REASONS) REQUES PROV DATE: SIGNATU, AP__ 6fffOF CO2. _. _.ITY DEVELOPMENT mar-f-IFLeave ShaKWApp is Caton (Tb-fw-cumptetud by Physiden) Physician's Release Statement t.Name ofiRS-EmpioYea T.Name ofFatient,3fs ftrent 3-k ,.Jw,p care far T� IFIE 4.wbat is offtpatients medi at conditfonT(Please bespedliic and.da=wt hWherrond tion-dearlyso-theApWovft ORideft wlJfbe able-Ruse-#his -of Nte 5OIA6--r WANJ 500-M 5(-Wr-r%-17jY- b4 f W- 4 J-5 . 5.Is required Rx Mentedical condition? Q'Ye$ No #so,dates:From: To _T- 6-Was the patient-seen Wae,-pleawAeswlW N0 T-Whatis.youc uw 8.What is the expected duration of the patient's medical condition? From: To` C Fi g.-C�be D-©-ful"irr%Hh*t vvhert? oondVJM 10.You may attach addiGonaTinTormatfoh that you Teel wff assfisf the approving officials in reviewing this application. Physidan's Date - PrrnfMame Prone R�* street Y�l This turrrrShuow'd tff reftff nadlmempWer Forrtr-1-2 (7-20o4 cat.-Na.-mw- publish.—Ir g� I sti�11"tsfthi�fteasury--tsWuslarlti vYRuaSilt Part 11 Leave Sharing Application (To be completed by Physkian) Physician's Release Statement 1.Name d IRS 6nployee _ . 2 Name d Patient.if different 3.H61NUV has tine patient been under your care for THIS SPECIFIC medical condition? 4.What is your diagnosis of the patients medical condition?(Please be specific and document hisNw conAlor►dearly so the Approving Offidals wgjw*ble Arnse-ars r _ 6.fitAoap WYes ❑No -tfao.ddes:Fw= To . V s 6 w"ft paftj seen on m ,plewe demb6 T.What Is your pognosis'd to paBanrCs WACkW Condition? 8.What Is the epected duration of to patienti's medical condillon? Frem!- - To, } 9.Can tine patient return Oo❑to .Ww duty O pwMne duty?9 to.when?Indicate any work I Nol, l imposed by ttds mi dial condiiton ULYou.may- edcMonaT that kou teat wi assistthe opprovinQottiddsln revlewing_P application►• T _ 0 f PlWgdan's Signab" Vtft i-- 'j fib} CT -I�- Mint Name Phene AIW li Street • T-l�#ertr� rld-bef�#e-efflpl�yeF PMB#300 6947 COAL CREEK PARKWAY SE -04/24/2003 Insured: ECKMAN,LAWRENCE EUGENE Claim Rep.: Rick Martinich Business ( 25�653- 552 Estimator. Rick Martinich Business: (425)653-5552 L/R NUMBER POLICY NUMBER TYPE OF LOSS DEDUCTIBLE 006 0090AHOM0001 P`H� iflii�*=>- $0.00 Dates: Ha Contactud: 0"7/03 Daft of lms�-• 4 ° S-ummary for P�E/SM6lKE Line Item Total 121,814.93 Overhead- t#0%, x- 12- ft4:93 12-,181-.49 Profit @ 10.0% x 121,814.93 12,181.49 Sales Tax @ 8.300% x 146,177.94 _ 12,132.77 Grand Total 158,310.68 t i� Rick Martinich Notice:USAA will not accept supplements to the estimate unless it is for an item we have agreedis pending,or damage that was hidden.In either event,USAA must have the opportunity to re-inspect prior to supplemental work being done. 1911 SW Campm L ... . n,, PM9*437 FederaLl my_"98Q23 July 8, 2003 LAWRENCE EUGEWE EOKIV�AN 17298 STATE ROUTE 3 ALLYN WX 76 Re__ US. . ra� ence-Eutlene Eckman USA,k Namben 7-33 30-- Dear Mr. Eckman: TtIiKis concerning your cfaia_fcwfwe_daMage to youi persona,P ply A baneticiaLportion ot=your- poky-is-the Loss•Settlementp,u-nst(HTFnat provides-for Propel Ly- iVbsesto-bL replacement cost witFXK* deduction fvrdepreciatfon. However, when theclaim-exceeds$500rwta.,_ifi_payc no mere than the actual cash value until repair c cs. acement-ot-the-aamavvd-p")petty is completes tang event vAlI_tbe_pojjcy p than-the-actual-cost#v-repe=r-w replace the-damaged property- YUU_�itt soon paymen€fbF the-actua4 vatreof-your-colAm As .,ss: Thy breakdown-is-enclosed with-this-letter, re acemeat:oUMG�wemn 18-completed, please senrxsa copy ofitho-w--eipt-as- veFif+cation# the--item wasrepfawd: Pfeawinckide the line Aem nur r with tFe- ctacumentation. You onry need-to provide receipts fortheitems dW, edi tod. l -itgKethjs m.+ii.�� aC�y<�regard-mg ��rrrc�r�r, please contact me_ fly, propeMy Claims Ac#uster t -CasuW Casuran(wGbmpagy encl. Rey0iAddress_ . 718 Claims 14N30-531-R777 PnFiry Cnnoww 4 ann C i4 04 4 4 ■■►fir'bW- ���■I■iir�i►:�ii�l1■■■■■■■■■■■■■■■It■ PROFILE.TOPOGRAPHY Building Peffnit number i Oww/Appllcant j► Par.cel 1 mommoommummmmmmmmummmmmmmmm■■■■ ■■m■■■■■ummmmm■■moommmmmmmmmm■■ ■■u■■■■mmiummomm■■■■■u .'maimaumm■■ ■mI■■��.'mmjummommm m■mmmm m■■■■l■■ ■■im i l �■I�iiil is i�li���■ mmmm mm■m 10 mmommadmImmomazommmmmmmmmmmmmmins m■■mm■/%1 mmmmzm■■■■■m■■■■■■■mI■�! ■■■■Imm''mmimm■ummm■m■mmm■■mm■■■■I■■ ■n,mmimmmut mmmmm■mm■■m■■■mm■■■■I■■ ■■■■iimoim■i1■■mmmmmm■■m■■■m■■■■mmism onimmimmmalzommmmmmmmmmmmmmmmmmmmI■■ ■■'■■I =lsimma■m■■mmmmmmm■mm■■■m■■mism ■■mo■m■ ■■MES■N ■■m■o■om■■■■oo■ PROFILE:OGRAPHY . r .. . Date of appli tio Env. Health: /// '■ ' d+e Sample Site Plan and Topography s8f,�`ye lde Qtj]6,de '� es eoe cohepfo'aEns t to�re r0 sitedoas r PlanSCale: 1 =40' �er4res� oseQ,s'drs'ra��es Main Street All se �� ro _.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.._.. The �r,FQ �.�,r• e _.._.._..._..._.._.._.._.._.._.._. Pro r.._.._.�.._..�.._.._.._.._.._. _.._.._. _. .. sejst�+c drQ�hre! i 1 i more Y be re ttge loc ? I 1, �ow$b��u feet w°ned,o° I I it Reserve Drainfielclaggr�ne ! i 104' <a:« !o io 1 Draii ifield �:.. iO3 i 1 .: Stormwater o- i 225' run-off path 20' Cry I m 1 PCO --- -�----------J6'56' ------- - 40' :a, Ico �• i 1 114 Existing iCD 1 Garage Y Wetland 1 i Buffer Zone 1 $ 171' ! 125 € ' I 1 � I i 1 a 1p i Allowable Building lipioj� I 9 i 1 ffi ! Area rd0 € 1 ` '0' 1 l� Well3 of i s I North +45' +5' 0' 68 55 40' 25' 36' 36' 35' MASON COUNTY DEPARTMENT OF HEALTH SERVICES it, Health Personal Health PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 BELFAIR(360)275-4467&4468 Application for Determination of Adequacy Instructions unttl::P :::: x. : .r:: c:ctteamanatto.:. .::::::::::a ::::::.::..:.:.........::..:.:. :::::;,;.::::<::::..:.::::.;:.;:.;:.;: .:::::......:.::::::.:..:: ........:............. ::: :::::.:.::............:::::._::::: ::::::::::::::::..:..:................:::::.::::::::.::::::::::.:::::::::::::..::::::.:.:::::.::..::.............. WRIM :.;;:.;:;;.;:.;;;:..• +aaatV: .:.. .... .�t# :*W .:.....:.::::::::..:.:.... 1 .:..... ........:. PART 1: Applicant/Parcel Identification Name of Applicant (,XAJIZW(;F-- f- NlAJ Date a 2V V3 Mailing Address 1 Telephone ZE- 6 714 Assessor's Parcel Number 1 Z - 200 4- Type o Water System Check One): Reason or Application Check One): ❑ Public/Community Water System(2 or more Building permit connections) ❑ Land use application,if so.. ❑ Individual water source(one connection),if so.. ❑ Division of land V_ Well #of Parcels? ❑ Spring/surf ice water SPH9 - ❑ Other(explain) ❑ Boundary line adjustment ❑ Other(explain) X I I J7FSTrLO�I fD 8�f �I 12� 107�03 -ri�IS IS /� �Gt1L6�w1�T I-Ff PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adequacy: Public Water System Name of Water System Water Facility Inventory(WFI)Number: ❑ The water purveyor has filed a letter granting blanket hookups to this water system. ❑ I am the manager of this water system. The water system has been approved for services. There are presently connections in use. This will be the connection.7S water system is able and willing to provicZe water to this(these)connections wi out exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date K I WDATAfRCMMWATERAD3.WP Update:March 22.1999 W - 7 Individual Water Well ❑ Water well report(attach to application) Depth ft. ❑ Well capacity test(attach to application) gpm gpd Well ca acity tests are often performed by the well driller at the time the well is constructed Test resultsTrom these tests are noted on the water well report. Results from these tests will be accepted. If the water well report cannot be located by the applicant or if the water well report does not have a capacity test, a well capacity test, which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. ❑ Satisfactory bacteriological test(attach to application) y Individual S rin /Sur ace Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ I have reason to believe that this water source can provide at least 800 gallons per day and/or provides water at a rate of 2 gallons per minute based on the following observations. AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT In addition to providing the above statement, the applicant will need to arrange an on-site inspection by the health department prior to determination of adequacy. Departmental use only. Do not write below this line. 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