HomeMy WebLinkAboutWAT2021-00135 - WAT Application - 1/29/2024 unu4-S
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MASON COUNTY
COMMUNITY SERVICES
au0dim}Phmrhg,EmironmeMal Health Cnmmunhy Hmhh
415 N P Street,Bldg 8,Shelton WA 98504,
Shelton:(360)427-9670 ext 400 4 Betfair:(360)2754467 ext 400 4 Elms:(360)482-5269 ext 400
FAX (360)427-7787
Application for`Determination of Adequacy
Instructions 01 m G JIEO fonsc- l¢,ypp -4---) -
1. Complete Part 1. P1 determination can be made until Part 1 is fully com feted.
2. Complete only the rtion 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 onApplicant—&1al L,21�n l LY EK-4J Data: I-Zq"2p2I
Mailing Address: rYll'IAM tL 5f ^E^E Phone: a,S 4 -10(03J0
Parcel Number.: f�J,J)�Pj . ��pp3 3DI �.6411aJoOe, lilA -AG 33Z
Type of Water System Reason for Application
XPublic/Community Water System(2 or more Building permit Nm 2.p21 -WID a3
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
#you have more than one residence connected system below if applicable-no signature
to this well,check the Publio'Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Pu Iic Water S tem
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(Le.: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)connections)without exceeding the
limits of the water system or any limits set by stale and local regulation.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
PN Fo�Dri ,Wa¢r Revised 3/19W21
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This form may be scanned and available for public view on the Mason County Web site.