HomeMy WebLinkAboutWAT2022-00193 - WAT Application - 6/30/2022 `ti MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 ;. Belfair: (360)275-4467 ext 400 4., 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 completed application, with attachments to the health department for review.
Part 1: Applicant! Parcel Identification )
Name on Applicant: Q 1(pKKV 2t\I �1f+�Lk, Date: L/ -!`2
Mailing Address: P, 0 t a i_ Z i, ,C I Fit,r Phone: 360 27)- 09 17
Parcel Number:: (V1J--°1 ' 411- `i c? 2-1 0
Type of Water System Reason for Application
WPublic/Community Water System(2 or more B Building permit
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Weil 0 Boundary line adjustment
❑ Spring/surface water 0 Other (explain)
❑ Other(explain)
0 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.
:APPROVED
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated: 'SUN 3 0 2022
MASON COUNTY ENVIRONMENTAL HEALTH
Public Water System
RE
Name of Water System: 3e/. ,'r i JaJer 4.,0rS lire Gf *.1
Water Facility Inventory(WFI)Number: a 5 3 S'(s (write"none"for two-party)
EAU
14 I am the manager of this water system.The water system has been approved for /1103 seiwiees.
There are presently SDI I {ne i (s) in use.This will be the $y2. 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 (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 provide water to this (these)connection(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager - wo £ Phone 21eD- 276- -3O 9
Signature of Water System Manager Date `'/7/202,2.
J:1EH Forms\Drinking Water Revised 3/19/2021
Page 1 of2
This form may be scanned and available for public view on the Mason County Web site.