HomeMy WebLinkAboutWAT Application - 10/1/2008 MA50N COUNTY
DEPARTMENT OF HEALTH SERVICES
Fnvironmental Health - Personal Heel
PO BOX 1656 SHELTON,WA 98584
LOCAL(350)427-9670
BELFAIR(360)2754467
Application for Determination of Adequacy FAX(360)427-7798
Instructions
1. Compete Part 1. No determination can be made unfit Part 1 is fully completed.
2. Compete only the portion of Part 2 applying to the type of water system utilized.
3. Submit oompfeted application,with attachments to the health department for review.
PART 1: Applicant(Parcel identification
Name of Applicant 641`Ili � - n nene G.r . jOADate IC'r -1-/IQ
Mailing Address?n 9i6 C 17 SI Telephone R7 74tf rl$
Assessor's Parcel Number
Tvpe of Water System Check One): Reason forA lication heck one
PublictCommunity Water System P or mom III, Building permit
�eaneoaoa:r• ❑ Land use appimlion, if so-
❑ Individual water source lone mnneceoe), ❑ Division of land:
if so..
Well #of Parcels? SPL
Springisurface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
'•if you have more than one residence ❑ Replacement(pease indicate name of water system
connected to this well,check the Public box. below Ifapplicable-no signature m9uimd)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System LA msn.
Water Facility Inventory(WFI) Number: S 1 9 a0 U)
(write 'none"for two party)
PE I am the managm of tgs water system.The water system has been as prrovv�ed for a�ervices.
There me presently connection(s)in use.This will be the a-�x wnWFt' .
❑ lam the manager of this system.This connection will be m up$mde or change the use of an
existing connection on this system(ie:recreational ful
l ll time).Please indicate on the following
line the nature of this change:
This water system is able and willing to provide water to this(these)connection(s)without
exceeding the limits of the water system or myyahmits set by state and local regulation.
Signature of Water System Manager �c -C Date/O-/-V�/
Upd+te:ApN 2006