HomeMy WebLinkAboutWAT2024-00071 - WAT Application - 1/9/2024 I ((. V1�A�2o2� -000n
MASON COUNTY
COMMUNITY SERVICES
eulNhg,Vbnninq Emlrmmentel Mrokh Communiry Health
415 N B"Street,Bldg 8,Shelton WA 98584.
Shelton'. (360)427-9670 ext 400 A Belfalr.(360)275-4467 ext 400 P Elma:(360)482-5269 ex1400
FAX (380)427-7787
Application for Determination of Adequacy L
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 �1
Name on Applicant: ,,>-S �Jes1-a..Y..CS Lu, Date: , �1
Mailing Address: 4y't ld�A.a..fS trr Uaw.+. Q4t� Phone:: &o lok m4s
✓ 0.8L�a
Parcel Number::
Tr>\x RQI SRty�otS
Type of Water System Reason for Application /
tL Publlc/Community Water System (2 or more W Building permit
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.
Part 2: Water System Information APPROVED
Complete the section appropriate for the type of water system being evaluated: MAR 0 5 2924
r-' Public Waters stem ' 'SCNCCUNTYEWRONMENTALH T
Name of Water System: Y A.L-� rN t,e0l
Water Facility Inventory(WFI) Number. ! j7a/
(write"none"for two-party) G�
I am the manager of this w t system.The water system has been approved for rT services.
There are presently Lwconnection(s) in use.This will be the qNS 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 (I.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system Is able and will to provi Water to this (these)connections)without exceeding
the limits of the water system or an limbs At y state and local regulation.
Signature of Water System Manager Date
J.TH Forms\Drinking Weler - Revisctl ILIIIS
Pegc 1 of2
This form may be scanned and available for public view on the Mason County Web site.