HomeMy WebLinkAboutWAT Application - 6/26/2018 s NV r g4ty 011,
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health ._
Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
AIR(360) 567
Application for Determination of Adequacy BE�FAX(360)4277-nse
Instructions
t. Complete Part 1. No determination can be made until Part 1 is fully comoleted
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 IdentificationName of Applicant 2I ?o„r4.,- 'bw 116,5 W1 e Date b- Z-1S
Mailing Address 29 11h 102 t Ow4rd Telephone"4603403311
Assessor's Parcel Number( lW(J _ y • 00003
eDe ofCWamfer Ssm One): Reason fo r ton Check
public/ omunit ec
yW 2ornom ❑ Buiding One
Connections)- ❑ Land use application, if so..
❑ Individual water source(one connection), ❑ Division of land:
if so..
Well Oof Parcels? SPL_
Spring/surface water ❑ Boundary Itne adjustment
❑ Other(explain) ❑ Other(explain)
"If you have more than one residence ❑ Replacement(please indicate name of water system
connected to this well, check the Public box. below if applicable-no signature required)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water S nitern
Name of Water System
Water Facitf Inventory (WFI) Number.
(write'non e for two party) 4 5()G!D rL
❑ I am the manager of this water system.The water system has been ap vedfor�servioes.
Them are presently Sty S connection(s)in use.This will be the=connection.
❑ I am the manager of this system..This connection will be to up or change the use of an
existing connection on this system(im recreational to fill time .Please indicate on the foIlowing
line the nature of this change.
This water system is able and willing to provide water to this(these)connectiol�(s)without
exceeding the limits ofthe water system or any limits set by state and iota)regulation.
Signature of Water System Manager 1 Date ° I f-'
Up&a ,Apd12006