HomeMy WebLinkAboutCOM2022-00073 - COM Water Adequacy - 8/31/2022 �t,soN Cou v Con "&D E D
Public Health AUG 31 2M
615 W. Alder Street
PO Box 1868,415 N tie Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9570 9M 400 O Belfalr.(360)275-4457 ext 400 O Elme:(350)482-6269 sd 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 co fated application,with attachments to the health department for review.
Part 1: Applicant/Parcel identificatlon
Nameon Appiicant:�tNMailing Address: 1.0 ,3orcZ389tige.CG..;i, ha'�is,': 36c7 " 7 1- 33 4
Parcel Number: IZ3 Z� I y40 Oln f7
Ito t U--% Ct $S"zg
Type of Water System Reason for Application
❑ PublioCommunity Water System(2 or more ❑ Building permit
connections)- ❑ Division of land:
❑ Individual water source(one connection), a of Parcels?_ SPL
❑ Well ❑ Boundary line adjusbnent
❑ Spring/surface water ❑ p1her(explain)
❑ Other(explain) j,'_°,/
Replacement(please indicate name of water
H you have more than one residence connected system below if applicable-no signature
to this well,check the PubIn Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
!7J
Public Water System
Name of Water System: Se-1 4 iA AALe
Water Facility Inventory(WFl)Number. O SZY"
(wrile'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.
ir! I am the manager of this system.This connection wig 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: /fP- -ooct
This water system is able and rovide water this(these)connadlon(s)without exceeding
the limb of the water system any lino set q'Mato a d regulation.
SigneNre of Water System Manag Date
R<••'ix4)2e 13
PWt2
This torn may be scanned and available for public view on the Mason County Web site.