HomeMy WebLinkAboutWAT2023-00214 - WAT Application - 8/1/2023 vvir ed.3 - da2l�
MASON COUNTY
. .'`i COMMUNITY SERVICES
A Building,Planning,Environmental Health,Community Health
415 N 6`"Street, Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair:(360)275-4467 ext 400 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 £ e: / /
Name on Applicant: Lief] !iv i✓ L�(fIin4; / /
M I 2-3
Addr ss: j57.,/�W (��DiU//>e t1 Phone::✓✓✓✓✓ (<- ) 223— S-237
ywirtei IN
Parcel Number.: -3/ 4'5 3O 7/ , 3 9 '/S cr>0-7L
3 D 3.7v/q/ r' tvi9 9rS-e `/
Type of Water System Reasofl for Application
Z. Public/Community Water System (2 or more lA Building permit 81f.D.O?3-OO' (oD
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
0 Well ❑ Boundary line adjustment
0 Spring/surface water
❑ Other(explain) 0 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. d Pp
Part 2: Water System Information I, Ro VC
u
Complete the section appropriate for the type of water system being evaluatet7ASQN SEP '0 20
CO ?3
uNry
Public Water System 684%,
Name of Water System: r �L`.� t� c��e_ Rer AZ
yLALTH
Water Facility Inventory(WFI) Number: Ll7 /3I
(write"none"for two-party) /�//a/. I am the manager of this ater system. The water system has been approved for%r services.
There are presently hiF/ connection(s) in use. This will be the '/`/2--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 provip e water to this (these) connection(s)without exceeding
the limits of the water system or an limils7691y state and local regulation.
-23
Signature of Water System Manager ;Yr`'2 Date
J:\Eli Forms\Drinking Water Revised IJIJI5
Page I of 2
This form may be scanned and available for public view on the Mason County Web site.