HomeMy WebLinkAboutWAT Application - 8/22/2013 (2) klw4Yr Yreltl aSakr. ve ealth •�
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7 e 415 N a"Sheet, Bldg 8,Hheitcn WA 9E564,
___-Shelion:(360)4 70 e 440 o BeRelr(350)275-4467 exd 400 t �ma:(3Sp)48232aB eO 1pp
FAX (3110)427-TW
Application for Determination of Adequacy
Instructions
I. Complefe Par['O,M aterrnnaBor)can'by ritade.unhl Park l; fbllncomulet :- - .
2 Complete orNl!;the ParRonotp 2apprym8.9?:'?�}eYXpA ofwad_iF Yst@m Wlized:.
3 Submit cornpletida 4cahon:wlthatlaellmkMlfa,tothattealth:de m[for.review
Part 1: Applicant!Parcel Identification
Name on Applicant'First Olympic HoL nn LLC Date: Ado oaf 22,2013
Ma7ing Address: PO Boa 997 C'e Harbo WA 98335 Phma:: 253.&57.8580
Panel Number.: 12329-42-00190
Type of Water System Reason for Application
9'PubllcrCommunity,Water System(2 or more &.,Buildirg permit
connections)- ❑ Division of land:
❑ individual water source(one connection), #of Parcels?__
❑ Well SPL
❑ Springlsudaca water ❑ Boundary line atljuafrr. t
❑ Other(expialn) ❑ Other(explain)
ff you have more than one residence connected ❑ Replacement(please indicate name of water
to this welf, check the Pubfir✓Commandy KWor system below ifapplicable-no signature
required)
System box. .
Part 2: Water System Information -- - IL
Complete the section appropriate forthe type of water system being evaluated: _
Public
/Water S st
m W em
Name of Water Syste a
wafer Facility Inventory(WFI)Number. 053SU -cO /6 -
(write"none'for two-party)
I am the manager of this water system The water system has been approved for Ste"LearWaes; J
There are presently ` connection(s)in use.This wit be the S oennectiom
12 1 an the manager of this system.This connection will be to upgrade or change the use Oran existing
r corection on II )SIP ease indicate on the following On,the nature
of this charge: L�iBA' f b
This water system is able and will'mg to provide water to this(these)connection(s)WM W exceeding
the limits of the water system or any limits set by an coal regulation.
Signature of Water System Manager 2�2Date 8. 2
R.ir Iwo
This form may be scanned and available for public view 001 the Mason Co rrss 1 x:
County Web site.