HomeMy WebLinkAboutBLD2007-00698 - BLD Water Adequacy - 5/30/2007 MASON COUNTY
DEPARTMENT OF HEALTH SERVICESRECEI�J
Environmental Health ersona!Health
• PO BOX 1666 SHE TON, WA 98584
MASON COUNTY LOCAL(360)427-9670
BELFAIR(360) 75-4467&4468
Application for Determination of Adequacy
All I
Instructions
CCoommple te PaA I. N o determinati 2 applying to P< art 1 is tr_lIy coomadu ofatytethetypwFJ, —Submitcomplet
plete rteda lication with attachmentstothehealt mm pulteiltiezde.d de artment forieview.
PART 1: Applicant/Pareel Identification
Name of Applicant Date 5 0 01
Mailing Address I'7 C • Gat oe.LcQ YL j . Telephone 31oo-`I 3 Z Z t 9 '1
DAQ i W-N t,• 8 QSk�V
Assessor's Parcel Number
3212 -1
Type of Water System Check One : Reason forApplication Check ne :
Public/Community Water System(2 or more p Building permit
connections) ❑ Land use application, if so..
❑ Individual water source(one connection), if so.. ❑ Division of land
❑ Well #of Parcels?
❑ Spring/surface water SPH9=
❑ Other(explain) ❑ Boundary line adjustmen
>( Other(explain) z —
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequ cy:
Public Water System
Name of Water System
Water Facility Inventory (WFI)Number: i5 l
❑ The water purveyor has filed a letter granting blanket hookups to this water system.
❑ I am the mansgeF of this water system. The water system has been approved for /�5 D services There are
presently //Y4 connections m use. This will be the // connection. is water system is able and
willing to prov cTe water to this(these) connections wl out exceeding the limits of the water sy em or any
limits set by state and local regulation.
Signature of Water System Manager Date -
H:IWDATA URCH/VEIWA TERAD3.WP Update:M irch 22, 1999
lA/ -