HomeMy WebLinkAboutWAT2021-00096 - WAT Application - 1/29/2021 _Bid�3 - 2-'4 u n�fS
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MASON COUNTY
COMMUNITY SERVICES
WMln%Phmio Em rhenblHWft, mm,mhy Hedth
415 N 6-Street,Bldg 8,Shehon WA 98584,
Shelton:(360)427-9670 ext 400 6 Beeair.(360)275-4467 ext 400 0 Elms;(360)482-5269 ext 400
FAX (360)427-7787
Application for Determination of Claque y
Instructions m�IG a�JnS2-'� V t eW "I P
1. Complete FV 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 department for review.
Part 1: Applicant/ Parcel Id�entificatio�n-- - � I'
Name on Applicant: lf[U/t,�� •YYIk.YL'FSn Date: -2f1•Z02. I
Mailing Address: I15QOC &rn Ai ry1DR..'� Phone: 2Cj51,5-1LP111t -O(.P'3tp
Parcel Number: IA3 -.min-LY)L10 '-- c.{I�.Tbi — T&cjoate. LOA 'AG 33Z
Type of Water System Reasons for"Application q
XPublic/Community Water System(2 or more Building permit &M 2AZ•I -t60 1 1
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
Ifyou have more than one residence connected system below if applicable-no signature
to this well,check the Public/Community Water required)
System box.
Part2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Pu Iic 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.
❑ 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
J:tBB Fmmst DriNiag watt Rm,xl Y192021
Page I aft
This form may be scanned and available for public view on the Mason County Web site.