HomeMy WebLinkAboutBLD2013-0068 - BLD Water Adequacy - 1/29/2013 ` 61dSvc3 - coci_qg
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Always wonting for Mason County
PO Box 1666,415 N 6' Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 0 Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for Determination of Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water system utilized.
3. Submit com leted application,with attachments to the health department for review.
Part 1: Applicant/ Parcel Identification k Ala
Name on Applicant:
/ '/- /� ate: Q/-alg— /3
Mailing Address: 6 O Lr,S4-4-hrk 4 Le Qr: Phone:: 3G c7 -&7 O
Parcel Number.: a a /a7. S/- o n U 3 y
Type of Water System Reason for Application
Public/Community Water System (2 or more Building permit
connections)" ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well❑ Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
Replacement(please indicate name of water
If you have more than one residence connected system below if applicable-no signature
to this well, check the Public/Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
, II Public Water System
Name of Water System: �t-45 t7e
Water Facility Inventory(WFI) Number:
(write"none"for two-party)
❑ lam the manager of this water system. The water system has been approved for services.
There are presently connection(s)in use. This will be the connection.
I am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on this system(i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willing to provi wat r to this(these)connection(s)without exceeding
the limits of the water system or a t by s to and local regulation.
Signature of Water System Manager Date O- O/3
Revised 3/15/2012
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