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HomeMy WebLinkAboutBLDG B - WAT Application - 11/7/2002 MASON COUNTY 7RJ if -B DEPARTMENT OF HEALTH SERVICES : .) 11 • Environmental Health Personal Health PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 BELFAIR(360)275-4467&4468 Application for Determination of Adequacy Instruct ions ns ....� art I.:is: co ;Com lete`Parx 1 Tio detertixmatign can be made until P fu�1Y......�!p 1 the ortton of Part 2:a :�:l .ing to the type:of whit; Com .lete on p:. . PP Y .:::.,:,::::: <.f:,���><�Y`::° 4��ry•< 3.. . ; .. Sul mit completed application,with attachments to the health :. t>filet a x... ::.>;:<.«:>.;<:� .....,v:r:>:,<-<?' PART 1: Applicant/Parcel Identification Name of Applicant /e Date /1 C/7"O a Mailing Address fb 7_5 8 E., Telephone 3lO,e7S=t 23 Assessor's Parcel Number / 233 a .S© O®9 T e o Water System (Check One : Reason or A lication Check One : p/ Public/Community Water System(2 or more 0 Building permit connections) o Land use application, if so.. o Individual water source(one connection), if so.. ❑ Division of land ❑ Well #of Parcels? o Spring/surface water SPH9 - ❑ Other(explain) ❑ Boundary line adjustment ❑ Other(explain) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adequacy: Public Water S stem Name of Water System -3EL tG4-/, err._ s 4� / Water Facility Inventory(WFI)Number: ❑ The water purveyor has filed a letter granting blanket hookups to this water system. o I am the manager of this water system. The water system has been approved for services. There are presently connections m use. This will be the connection. This water system is able and willing to provicTe water to this(these)connections without exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date H:IWDATAWRCHIVEIWATERAD3.WP Update:March 22,1999 W - 7