HomeMy WebLinkAboutWAT Application - 7/1/2004 / MASON COUNTY
DEPARTMENT OF HEALTH SEPVICE5
Emwomnenw!Hearth Personal Health
PO BOX I666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy
Instructions ,.
y
PART 1: ApplicautTarcel Identification
Name of Applicant /�C/-' ��� Date (/�.�/��� 0
Mailing Address U / Telephdde
W 36 o3�f
Assessoes Parcel Number 322-32— 52 1-5Z,05
Type of Water System Check One : Reason forApplIcadon Check One):
PubBclCommunity Water System(2«mwe ❑ Building permit
w�) ❑ Land use application,if so..
❑ Individual water source(aoe moeatioa),if so.. ❑ Division of land
❑ Well #of Parcels?
❑ Spring/surface,water SPH9_—
❑ Other(explain) ❑ Boundary line adjustment
❑ Other(explam)
PART 2: Water System Information
Complete the section appropriate for the type of wafer system being evaluated for adequacy:
Public Water S m
Name of Water System
Water Facility Inventory(WFT)Number:
❑ The water purveyor has Mod a letter gmmmg blanket hookups to thin water system.
❑ I am the manager ofthawater system 'ihe water system has hem approved for secvica. 11hem are
1�K com«tiaatimuse. ThiswiLLbe the cmoecdm ltiawsysystem is able and
wi�Wv' gyro ppIv water m this((these) ecucm aaediag the limits of the water system or any
limits set by state and local reguletio
Signature of Water System Manager ' Date 7 )
HMWDAT.4WX W6IWAMUDt.WP tlpdn Much 22.1999
W - 7