HomeMy WebLinkAboutCOM2014-00044 - COM Water Adequacy - 3/7/2014 *?,,SON COrjNr�
Public Health
Always worMag for a r healthier Mason County
PO Box 1666,415 N 601 Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 v Belfair.(360)275-4467 ext 400 -:0 Elms:(360)482-5269 ext 400
FAX (360)427-7787
Application for Determination of Adequacy
Instructions
[2.
Complete Part 1. No determination can be made until Part 1 is fully completed.
Complete only the portion of Part 2 applying to the type of water system utilized.
. Submit completed application,with attachments to the health department for review.
Part 1: Applicantl Parcel Identification
Name on Applicant: Hood Canal Communications Date: March 7,2014
Mailing Address: PO Box 249,Union,WA 98592 Phone:: 360-898-2481
Parcel Number:: 32232-50-94008
Signature: Date:
Type of Water System Reason for Application
® Public/Community Water System (2 or more ® Building permit
connections)'" ❑ Land use application, if so..
❑ Individual water source(one connection), ❑ Division of land:
If so.. #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ 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 box. required)
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System: Hood Canal water Company A
Water Facility Inventory(WFI)Number: 34050M
(write"none"for two-party)
❑ 1 am 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.
6 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: remains full time, no Changb
This water system is able and willing to provide water to this(these)connection(s)without
exceeding the limits of the water tem or any limit set by st and local regulation.
Signature of Water System Manag r Date 03I07/2014