HomeMy WebLinkAboutWAT Application - 2/21/1995 POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
APPLICATION FOR DETERMINATION OF ADEQUACY
Revleel 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 eyetem 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 CW Me= DATE
MAILING ADDRESS —_,TELEPHONE ( )
ASSESSOR'S PARCEL NUMBER -SA ' JIJ�O
ver.
SUBDIVISION (If Applicable) LOT
TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One)
Public/community Water System Building Permit, Single Family Res
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
El Individual System, Other ❑ Other
PART 2-A: PUBLIC WATER SYSTEM ,. .
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NAME OF WATER SYSTEMEl +FI ID
The wtec pYtweyor for t,L eyetem hem pmimoely filed a cemdfinate of voter ademmacy with no h olth
di.tti.t.
I an sooner of the shave reforevcM Water System. The water eyetem hoe Dag apptval for _ service
connection(, with _ aomnotion. presently Sn Wee. The applicent hem approval to cameo to We water
Zeyetem. service of watet to the applicant for doneetle porpoees i. eoneletant With hoh the water eyetem
plan and the water right per Wit proemntly in effect. water linne are evAllehle in the applicent'e property
line, or the applicant he. ands eetiefactory arrangemente to attend the llnem. - '
g1gm21ME OF STRIE1 MARACER DATA
W-7