HomeMy WebLinkAboutBLD Water Adequacy - 6/20/2007 (,A
MASON COUNTY �l
DEPARTMENT OF HEALTH SERVICES
Environmental Health)S r , , yl n L Pe al l
PO BOX 1666 SHELTON, WA 98584
LOCAL(360)427-9670
BELFAIR(360)2754467
Application for Determination of Adequacy FAX(360)427-7798
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. Sukmit completed application,with attachments to the health department for review.
(Assessor's
ART 1: Applicant/Parcel Ida t,ifica�ti n
ame of Applicant��-//-or2d /1hnn9Y&-e Date l&.L107
ailing Address 1PS'orJ vWi9+c/ KD, Telephone &�-229—fsaR
Parcel Number 32 2 12 7/�a0T e of Water S stem Check One : Reason forA lication Check One Public/Community Water System(2 or more Building permit
onnections)— - ❑ Land use application, if so..
Individual water source(one connection), ❑ Division of land:
if so..
Well #of Parcels? SPL
Spring/surface water ❑ Boundary line adjustment
Other(explain) ❑ Other(explain)
If you have more than one residence ❑ Replacement(please indicate name of water system
nnected to this well,check the Public box. below if applicable—no signature required)
ART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System
Water Facility Inventory (WFI) Number:
(write "none"for two party)
❑ I 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.
❑ I am the manager of this system. This connection will be to up de or change the use of an
existing connection on this system(ie:recreational to full timePlease indicate on the following
line the nature of this change:
This water system is able and willing to provide water to this(these)connection(s)without
exceeding the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date
Update:April 2006