HomeMy WebLinkAboutWAT Application - 6/19/1998 Jun 22 98 08: 03a Jennifer Harper 425-644-4272 p. P
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POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
APPLICATION FOR DETERMINATION OF ADEQUACY FAX 427-2425
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INSTRUCTIONS
1. Complete Part 1. No determination can be made unt 11 Part i 10 fully comoleted.
2- Complete only the portion of Dart 2 applying to the type of Water Brat= Utilized.
3. Submit completed application, With attachments to the health department for review.
PART 1: APPLICANTIPASCEL IDENTIFICATION
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NAHE OF APPLICANT A-)1,1y. e�w a/ DATE
IflILINO ADDRESS TFLEPAONL LZI arl W�CI
ASSESSOR'8 PARML`NM=R 1 0 Fa / tbh,
sUDDMSION (If Applicable) LOT
TYPE OFF7 WASER fiY6'fFYi (Chock One) - REASON FOR APPLICATION (Chock One) -
'+a Public/Community Water syettn .Building permit, aingla FemLly Res
Individual System, Drilled Well Bu 1dLng Permit, Canmetcial
El Individual System, Dug well building Permit, Replace/Remodel
O'Indioidual 'Syatoo,:Spring - - 0 Land use Application
❑ Nme
Individual System, Surface Water - Type
Irdiyldual other ❑ other
PART 2-At PUBLIC.WATER SYSTEL!. ._
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MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
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PO BOX 1666 6HELTON,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
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PART 1: Appliccaant(Parcel Identification
Name of Applicant & dd-.WE427 Date
Mailing Address Telephone .
Assessor's Parcel Number
-130� 1
e o Water seem Check One . Reason or licalion(Check One1:
❑ Public(Community Water System(2a .o.a Building permit
.U..) ❑ Land use application,if so
meaoo ..
❑ Individual water source( k-),if so.. ❑ Division of land
❑ Well #ofPe[ceIS
❑ Spring/surface water SPH9
❑ Other(explain) ❑ Boundary line adjustment
❑ Other(Cvw
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
Water Facility Inventory (WFI) Number:
❑ The water purveyor bus filed a letter granting blanket hookups to this water system.
❑ I amthemanagaofthis water system. The water system has been appravod for services. Them are
presently connections in use. This will be the connechm -7Tius water system is able and
wdlmgm provlaTe watcto this(West)connecaons without ex the limits of the water system or any limits
set by state and local[egulation.
Signature of Water System Manager Date
W-7 H:IWDATAWRCHI WAYFBAD3.WP Update:0 ba20,1995