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Home My WebLink AboutWAT2021-00134 - WAT Application - 1/29/2021 E 24 Unto 0a+2D21 - ooj3L4 MASON COUNTY COMMUNITY SERVICES Bu06ng,PlamMe Emiranme�l Hrelth,Community H®Ith 415 N 6' Street Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 O Belfair.(360)275-4467 ext 400 O Elma:(360)4825269 ext 400 FAX (360)427-7787 Application for Determination of Adequacy Instructions 0 1 CJ !Sun Z> }' WE -� -A VYayL+5 - 1. Complete P 1. No determination can be made until Part 1 is fully completed. 2. Complete onT 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. i S Part 1: Applicant/ Parcel Identification Name on Applicant:Fy,- i��fYA T Date: I-2-q-7-0 2- I Mailing Address: I115O &rn1 4rY1 DIL 5fE-� Phone: 11� -tPlig-0to3lo Parcel Number.. I23�-Sn-[17G103 �I ' C1Ka44&tbm2- L0A '1G332 Type of Water System Reasons for Application XPublic/Community,Water System(2 or more AlBuilding permit &M 2U2I 'Oi 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 ff you have more than one residence connected system below if applicable-no signature to this well,check the PublidCommunity,Water required) System box. Part 2: Water System Information Complete the section appropriate for the type of water system being evaluated: Pu Ilc Waters stem 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 cennection(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 I:tEBFormet Dnnkirq Wr,v Rm"d 3/192MI Page 1 or1 This form may be scanned and available for public view on the Mason County Web site.