HomeMy WebLinkAboutBLD Water Adequacy - 1/25/2005 MASON COUNT
DEPARTMENT OF HEALTH SERVICES
Em ronmental Health Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy
Instructions
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PART 1: Applicant/Parcel Identification
NameofApplicam Tc7~62 'S, rf/RA/OLI) Date
Mailing Address D, 60 X 12 11 Telephone 3reo.70R- 7rf661
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Assessor's Parcel Number 3 a 13475q 003
7tpne of Water Svslem Check One): Reason forApplication Check One):
Public(Community Water System(2 or more (a, Building permit
COonCC60.) 0 Land use application,if so..
0 Individual water somce low connection),if so.. 0 Division of land
0 Well #of Parcels?
❑ springtsurface water SPH9_
0 Other(explain) 0 Boundary line adjustment
0 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 Water System �a-l�C dF..�
Water Facility Inventory (WFI) umber: 05'9/ 7.6
❑ The water purveyor has filed a letter granting blanket hookups to this water system.
0 1 am the manager of this water system. The water system has been approved for services. There are
presently �,L connections m use. This will be the SA` connection. 'line water system is able and
willing to prroovidce water to this(these)connection¢wit out r`�ceeding the limits of the water system or any
IbniLs set by state and local rogulation. / /—'J
Signature of Water System Manager L y %Z�• Date
H IWDATAURCHIV0WATE1AD3.WP Update.March 22,1M
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