HomeMy WebLinkAboutWAT2021-00097 - WAT Application - 1/29/2021 (� Ida+2021 - aooq-#
MASON COUNTY
COMMUNITY SERVICES
Bu W iy Plenniny Environmental!W ltlb Cemmun 6Y HnM
415 N 6a Street,Bldg 8,Shelon WA 98584,
Shelton:(360)427-9670 ext 400 4 Belfair.(360)275-4467 ext 400 O EMa:(360)4825269 ext 4W
FAX (360)427-7787
Application for Determination of Adequacy
Instructions 01 mpc, vl
1. Complete Pan 1,Mo 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 department for review.
Part 1: Applicant! Parcel Identification
Name on Applicants—&AJL —Awh+ Data: 1-25.2n2I
Mailing Address: I I5053uf-nhA ry)b IL V� ^E Phone: a5�i-(�49-OCv3Sp
Parcel Number.: l';3Ab-Sn-00003 - �tcy++&Abae- LOA '1B332.
Type of Water System Reason lfor Application
XPublic/Community Water System(2 or more Building permit 66M 2.0 2-r -0601a
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement(please indicate name of water
If you have more than one residence connected system below if applicable—no signature
to this well,check the PubliclCommunity Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Pu Ilc Water System
Name of Water System:
Water Facility Inventory(WFI)Number: (write"none for two-party)
❑ 1 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.
❑ 1 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
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Page 1 of2
This form may be scanned and available for public view on the Mason County Web site.