HomeMy WebLinkAboutWAT Application - 10/21/1998 r
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Eavlroamsata)HmhL Water Qaahty Pe.aoaal HealrA
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275.4467&4468
Application for Determination of Adequacy TOLL FREE 1-800-562-5628
FAX(360)427-7798
Instructions
] Complete Part 1. No determination can be made until Part l is fully completed
2 Complete only the portion oC Part 2 applying to the type of water system utilized
3 Sobrmt completed application,with au hru nts to the bealth department for Y iow.
PART 1: Applicant/Parc
el Identification
Name of Applicant k i e r Date /0
Mailing Address T4 Rn _ Telephone J
Assessor's parcel Number 1A iiC> ,&FT O O / ' ° ''^' a oo t c\
Type of Water System Check One : Reason Lor Application Check One):
PublidCommunity Winer System(2 or. Building permit
cmneuma) ❑ Land use application,if se..
❑ Individual water source if so.. ❑ Division of land
❑ Well Aof Parcels?
❑ Spring/surface water SPH9_
❑ Other(explain) ❑ Boundary line adjustment ..
❑ nn Other(explain)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water System
Name of lbygsmw
ystem ,`=.Sr`--'< « �S r`•, , l
Water Facventory (WFI)Number: i`- "3 SRO D
Thpurveyor has filed a letter granting blanket hookups to this water system.
Lam, nager of this water system. The water system has been approved for ZS services. there a d
pre 0 connections m use. This will be the 2 / connection. is water system is able and
wimvr�e water to this(these)connections without ez— m .9 the limits of the water system or any limits
set and local regulation.Signatureter Syatem Manager / Date
W-7 H.1"AAU9CH1MWATM([)3.WP upd .octAu 20,1995