Two Party Application

Two Party Application
415 N 6th 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 Review of a Two Party Water System
Permit Number
Payment Information
WEL
Receipt Number _________
 Cash
 Check
_____________
Date of Payment ________
Instructions
1. Complete Part 1. Incomplete applications will be
rejected
2. Make sure all required documents have been
submitted (well log, water sample and recorded
documents).
3. Submit application and fee to Mason County Public
Health. Refer to Mason County Environmental Health
fee schedule for cost.
PART 1: Applicant / Parcel Identification
Water System Name
Site Address
Applicant
Phone
Mailing Address
City
State
Zip
Parcel Number
Directions to Site
PART 2: Health Department Review (Staff Use Only)
YES NO
NA
Water Well Report with adequate pump test on file?____________
If NO, date of capacity test
Driller
GPM
Received Satisfactory Bacteriological Analysis? Date of test
Received Signed, Notarized, and Recorded Agreement or Notice?
System appears adequate to serve two single-family residences on information provided.
System Approved
System Denied
Comments
Date
Sanitarian signature
This form may be scanned and available for public view on the Mason County Web site.
J:\EH Forms\DRINKING WATER FORMS\Drinking Water - Application for Review of Two-Party Water System.docx
Revised:12/1/2015
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