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HomeMy WebLinkAboutBLD96-1176 - BLD Water Adequacy - 10/13/1992 10/13!97 MON 12:02 FAX 3604277798 MASON COUNTY BLD A — — Z 004 9191-PR Stflq,�-9 r 69LJ�lAfS 4 MASON COUNTY DEPARTMENT OV HEALTH SERVICES L Water Qualify Per oaal Health Enviro"Mcnfal Health ,WA q$5$4 PO BOX 1666 SHEL LOCAL,( 60)427-9670 13ELFAIR(360)27 44-67&4468 Application for Determination of Adequacy TOLL FRF,Xl� o)427 7698 Instructions atv«Sttll ) :C���eiq'Pact. detcrzltwA�2d. td�m�.e�t��TJ? 1 �-_'- ,— � µimpl`e�e.au�f"'hr�oruosrafl?arf�RPptyttt�` '�e.oEwatorc t" etL "' "" wlicauon,`�+#Ira �`�fft�'t©�lalCzaEQk,al ';ailiuo`�,�wvtc'tY . ., :., , 3 �. . �U`�PitsF�aiple�e�:up I�J1 d 1 1� to PART 1: Applicant/Parcel Identification ry Name of Applicant ��t S"A-i a Date — Mailing Address Telephone Assessor's Parcel Number OOcD LH Q-,v ( t lof `{3 Ty7 e of Water System (Check One): Reason Lor APPlicavon Check 0 e ❑ PublidCommnaity Wa[er System Ct^ mer= ' ❑ Building permit uoonwt:one) , ❑ Land use application,if so.. ❑ individual water SOUroe(we wmcotiaa),if so.. I ❑ Division of laud ❑ Well #of Parcels? i ❑ Spring/surface water SPH9= ❑ Other(explain) ❑ Boundary line adjustwerit ❑ Other(explain) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adegk1 y: Ak('C?L,t41C, Pablic Water System _ Pg Name o£Water System I I ` Water Facility inventory (WF )Number: I-VO 76 ❑ 77ie water purveyor has filed a letter granting blanket hookups to this water syslcrn. services. Tlterr are ❑ I am the a of this water system- The water system has been connection.onoved ` is water system s able and connection m use. This will be the l� ., Payvi wnnection without exceeding the limits of the water system a any lintils, ,,.to pro a ware to this(these) set by state and local regulation Date — Signature of Water System Mang 4�Lr M, jj,lif!pAT,•IViRCNflrfjl(FifTFRAD3.ii'F Update'.Clc her 2Q,1995