HomeMy WebLinkAboutWAT2021-00098 - COM Water Adequacy I�a+2o21 - coo S
MASON COUNTY
COMMUNITY SERVICES
Building FlemingEmi=menlal6 ,mmmunftyB ldi
415 N 6-Street Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 G Belfair.(360)275-4467 ext 430 9 Elms:(360)4825269 ext 400
FAX (360)427-7787
Application for Determination of Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water system utilized.
3. Submit completed application,with attachments to the health departmentlffor review. �( �^y
Part1: Applicant/ParcelIdentiflcadon OI U�r �I� I ""' �'�
\
Name on Applicant: Date: -2.q-202 �
Mailing Address: I1606 Zurnlri4rr1 b V_ 5�Phone: o�17'JJ-1s44' �(o 3�p
Parcel Number:: '-al — 6tr�.'t+&kjoOe- WAIAG332.
Type of Water System Reason lfor Application
XPublictCommunity Water System(2 or more Building permit ebm Z02-1 -0002-1
connections) ❑ Division of land:
❑ Individual water source(one connection), At of Parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement(please indicate name of water
t/you have more than one residence connected system below if applicable-no signature
to this well, check the PubtfdCommunity Wafer required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Pu tic Water System
Name of Water System:
Water Facility Inventory(WFI)Number: (write"none"for two-party)
❑ I am the manager of this water system.The water system has been approved for services.
There are presently connection(s)in use.This will be the connection.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(i.e.:recreational to full 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 any limits set by state and local regulation.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
1:\611 Fm \Drinking wad R ixd 31192a21
Pege t of2
This form may be scanned and available for public view on the Mason County Web site.