HomeMy WebLinkAboutWAT2024-00073 - WAT Application - 1/9/2024 VGA+ 2a+ booi7
MASON COUNTY
COMMUNITY SERVICES
BWlding,PlannNq Environmentd Neellh Community HmItM1
415 N 8"Street,BMg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4 Belfalr.(380)276-4467 ext 400 4- Elme:(360)482-6209 ext 400
FAX (300)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/ 11
Parcel Identification
Name on Applicant: k_ • y}a�et'S ,t, Date: • Ll
Mailing Address: q3+1 1a1$'b • 1-1 4- L Phone:: ILO lot -51 141Y
Parcel Number.: 3IAe�` j D 1 j, �(�C{(� $E�j(ed^a..� it
Type of Water System Reason for Application�n
M Public/Community Water System(2 or more t$ Building permIt ?)"u2q-bV K-I
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels?_ SPI,
❑ 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.
Part 2: Water System Information APPROVED
Complete the section appropriate for the type of water system being evaluetetl: MAR 05 2024
Public Water System MASON CO
Name of Water System: f� tk L-1 n "k.P _ RET NE4t
Water Facility Inventory(WFI)Number: 4147131
(write"none"for two-party) ' rQ'�y
I am the manager of T15 mor system. The water system has been approved for t V /esMees,
There are presently /�/S connec8on(s) in use. This will be the connection.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(Le.: 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 Oran line t y state and local regulation.
Signature of Water System Manager O� Date ���
JAEH Forms\Drinking Water — Revised twills
Page 102
This form may be scanned and available for public view on the Mason County Web site.