HomeMy WebLinkAboutBLD Water Adequacy - 8/23/2006 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Envkonmental Health - - Personal Health
PO BOX 1ee6 SHELTON, WA 9851
LOCAL(360)427-96-
BELFAIR(360)275-"
Application for Determination of Adequacy FAX(360)427-771
Instructions
1. Complete%. rt:l IVco dettttmlrMiihai card Ise
2. Complsbe ppti the prltfRNt ctf#rjs:t
3. Submit cohipletw.Soplicaft
PART 1: Applicant/Parcel Identification
Name of ApplicantMi arm._ *5�..�." wws Date R12-3lot
Mailing Address- l►-10 Telephone 3bo • b4 - `f3 4Z
Assessor's Parcel Number ►233 t- '4I - Ooo 6 it
Type oft owf rem chock_Qo _.__RM!W-10r.4 Icatfon Check-One
PubkdCommunity Water System(2 or mac ir Building permit
eonmeeomr• o Land use application, if so..
a Individual water source(one easmcaon), a Division of land:
N so..
Wall #of Parce69 SPL -
0 . Spring/surface water o Boundary line adjustment
a Other(explain) o Other(explain)
"If you have more than one seeklence o Replacement(please indicate name of water system
connected to this well,check the Public box. below If siVicable.-no signetwe required)
PART 2: Wathr System Information
Complete the section appropriate for the type of water system being evaluated:
Public YWater System
Name of Water System
Water Facility Inventory(WFI) Number.
( °none'for two party)
I an the manager of this water system.The water alstern has been approved for services.
There are presently - connection(s)in use.This will be the _ connection.
0 I am the manager of this system. This connection will be to upgrade or change the use of an
existing connection on this system(le:recreational to full time).Please indicate on the following
line the nature of this change:,
This water system is able and willing to provide water to this(these)coaleection(s)without
exceeding the limits of the water syslep or any limits set by state and local regulati n'.. /
g System Man Date `017 G'lv
Signature of Water
HAWEMWEBPAGEIWEB SMIWATEUN DOC Update:April 2006