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HomeMy WebLinkAboutWAT2023-00319 - WAT Application - 10/30/2023 oo MASON COUNTY wATO - 0031� COMMUNITY SERVICES / Building,Panning Environmental Health Community Health 415 N 60 Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 A Belfair:(360)2754467 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 ran 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: yt_Uqq, i(�,vYl S Date: Mailing Address: a, S , 6 !BCaaSS,r Phone:: 3 ,6;,0 - 7 90- 9176 � Parcel Number:: 9/J y S�P— oODGrs ��` fiKCF`/ Type of Water System Reason for Application ME Public/Community Water System (2 or more 19 Building permit 6LD&UV,3—Q/35a"" 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 PublicyCommunity Water required) System box. Part 2: Water System Information APPROVE ( Complete the section appropriate for the type of water system being evaluated: DEC 15 2023 Public Water System MASON COUNTY ENVIRONMENTAL HEALTH Name of Water System: r a-,—) Il L— tLF Water Facility Inventory(WFI)Number: (write"none"for two-party) I 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. 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. : recreational to full tirr}a),PJpase indicate on the following line the nature of this change: SAP.//./O(.f�R. ./ff7GGt�r-•fG(�'.cks�.il>C�� This water system is able and willi to provi wa er to this (these)oonnection(s)without exceeding the limits of the water system or an lim t y state and local regulation. Signature of Water System Manager Date / Y12 J.THForms\Drinking Water \ Revis 12/1115 Page 1 of 2 This form may be scanned and available for public view on the Mason County Web site.