HomeMy WebLinkAboutWAT2023-00083 - BLD Water Adequacy - 10/27/2023 ii
;Fir MASON COUNTY" VJA-1-/01f) d Oatf)
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;^; COMMUNITY SERVICES
r�l',r .4'' Building,Planning,Environmental Fiealth,Community Health
415 N 6'"Street,Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •: Belfair:(360)275-4467 ext 400 Elma:(360)482-5269 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 comoleted.
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
7 `
Name on Applicant: _,gin,,,, r �ipl`tea,),l s n Date:
Mailing Address: 7(A) -7-)J -1, )4 `,e, Phone: _ S&> _-!.6
Parcel Number:: '2Z.Zi.5-7.S='3 of)SY -
Type of Water System
Reason for Application
3
�Public/community Water System (2 or more
wilding permit - h-)l(1 Z�C. l�
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well • ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
O Other(explain) ❑ Replacement(please indicate name of water
If you have more than one residence connected system below if applicable—no signature
d ire )
to this well, check the Public/Community Water requAPPROVE�
System box.
Part 2: Water System Information APR 2 8 2025
Complete the section appropriate for the type of water system being evaluated:
4ta,SOy C 'J'tT"EttV1RUYIItN1AL Nt.Ai.TH
F1 Public Water System
Name of Water System: �sIJFF�A,\Z G3A-E2 AI - 'QC-
Water F cility Inventory(WFI) Number: 0 L/The_/a, has (write"none'for two-party)
I am the manager of this water connem.ection system in use. will bee ene a pro ed/6 connection.services.
There are presently /5- ( )
0 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 ter tot s (these)connection(s)without exceeding the
limits of the water system or any limits set by t to d I al regulation.
Print Name of Water System Manager f 4—,C'C - Phone ,WO �'e6- i998
Signature of Water System Manager Date %0%.7/�,
to Water �6w' 1 Revised 3/19/2021
Mil Forms\Drinking / Page 1 of
This form may be scanned and avail ble for public view on the Mason County Web site.