HomeMy WebLinkAboutWAT Application - 1/2/2018 V4� tam
ASON COUivJ,
Public Health
Always working for a sa/er resthier Mason County
415 N e°i Steel,Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 % Belfair. (360)275-4467 ext 400 ^ Elma:(360)482-5269 ex1400
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 t
Name on Applicant: Qwiyiii D lAimI `w•1 �t, Date: iin) IQ
Mailing Address: V.0.6N%)J4 Par riy E, l A Phone:: o• q 5• t Y
Parcel Number: 1111O� Sy' 16 116
Type of Water System Reason for Application
Public/Community Water System (2 or more ❑ 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
Complete the section appropriate for the type of water system being evaluated:
1 \ Public Walter System
Name of Water System: •9 y e
Water Facility Inventory(WFI)Number. 9b
(write*none'for two-party) Q
], I am the manager of this water system.The water system has been app�vve�d., for 17�ervices.
There are presently$'a�connection(s)in use.This will be the ff 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 provide water to this (these)connection(s)without exceeding
the limits of the water system or any limits et by state and local regulation.
Signature of Water System Manager Date ' / '
1 rEH Forms\Drinking Wamr Revised 12/IIIS
Page I aft
This form may be scanned and available for public view on the Mason County Web site.