HomeMy WebLinkAboutWAT Application - 5/10/1995 jpb MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1866
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
APPLICATION FOR DETERMINATION OF ADEQUACY
Aevleet 09/01/92
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
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NAME OF APPLICANT C• L'Okt.t 00� �"� DATE
MAILING ADDRESS O��IOXS �4g TELEPHONE 1-206 IZ75-S337
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ASSESSOR'S PARCEL NUMBER -- oe:_
SUBDIVISION (If Applicable) eat�S CO LOT
TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One)
Public/Community Water System Building Permit, Single Family Rea
Individual System, Drilled Well Building Permit, Commercial
Individual System, Dug Well Building Permit, Replace/Remodel
Individual System, Spring Land Use Application
Name
Individual System, Surface Water Type
❑ Individual System, Other ❑ Other
PART -2—A: PUBLIC WATER SYSTEM .
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9IONA1 ME OF SYSTEM MANAGER
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