HomeMy WebLinkAboutWAT2024-00127 - WAT Application - 3/4/2024 I A4-zbz4- ODI;'+
MASON COUNTY
IFCOMMUNITY SERVICES
Building,Planning Ewimnmenael Health Community Healu,
415 N 6"Street,Bldg 8,Shelton WA 98584.
Shelton:(360)427-9670 ext 400 •i Belfaic(360)2754467 ext 400 fi Elma:(360)462-5269 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
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Name on Applicant: [l, lltpa is l \ute: -3 a L
�aili-npy/ dddress G.�7 'f
aracel Numbe�g61� hone::
Type of Water System Reason for Application N1 � I
EL Public/Community Water System(2 or more ti Building pennit�IC12o244-190-Wi 1
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels?- SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ 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
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Part 2: Water System Information ~PP�OVED
Complete the section appropriate for the type of water system being evaluated: MAR 28 2024
r� Public Waters stem MASON COUNTY ENV)RONME LTH
Name of Water System: Y &- J n �-r6L4? _ Er
Water Facility Inventory(WFI)Number.�; (17131
(write'none"for two-party) y.�
I am the manager of ttys�yvFr system. The water system has been apprgyEd for_ro � services.
There are presently "!%N oonnection(s)in use. This will be the�N / connection
❑ 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 prove$,water to this (these)connection(s)without exceeding
the limits of the water system or an limits eRtly state and local regulation.
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Signature of Water System Manager 716•�' Date
J TH FonnsS Dnnking Wain -- Revised ILIII5
Poge I ,1'"_
q This form may be scanned and available for public view on the Mason County Web site.
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