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FORM MUST BE COMPLETED W M PERMIT NO.: BLD —vO (0 PLEASE PRESS HARD MASON COUNTY BUILDING PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 ; Shelton 360 27-9670 Belfair 360 27"67 Elma 360 2,6269 Seattle 206 644968 APPLICANT INFORMATION CONTRACTOR INFORMATION OwnerMARK .$TMM 0A C-C.IAA19/AI Contractor Name extAF-2 CDA17RAc-Tr-d Mailing Address R f f-•iV _ Mailing Address City9kC-m&i%Mj State WA Zip Code City State Zip Code PhoneL360 69Z-W33bther Ph.(2(o Ph.( Other Ph.( Lien/Title Holder Contractor Reg.# Address Expiration 'SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic--Existing Septic Connect to Sewer System Name of Sewer System WeIIC Water System Name of Water System PARCEL INFORMATION-12 digit Tax Parcel No. Fire District_ Legal Description 114 yGm LAMiz- �I Site Address(Please include street name,street nt�tm�er and city) 0219 1 ME 14A u f= T WA I Directions to site 364PA12-IMU4A 144 �2_/�1F Ni9!/i� 14/ E Will timber be cut and sold in parcel preparation?(Yes/No)JJ0 Is your property within 200'of the following:Body of Water(Name) W AyOA/ Z-AliE Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs PERMANENT RESIDENCE(] SEASONAL RESIDENCE❑ TYPE OF JOB New X Add Alt Repair Other_Use of Building Describe Work C 45 /STRl7CT N,iS sv /QrSS//�i+.ycrs No.of Bedrooms_c` No.of Bathrooms_SQUARE FOOTAGE-1st Ftoor/.2Oq 2nd Floor 7 i 3 3rd Floor Loft Basement LiFl2 DeckJ`�Other sq.ft. Garage�Attached _Detached Carport Attached_Detached_ MOBILE HOME INFORMATION-Make Model Model Year Length Width Serial No. No.of Bedrooms No.of Bathrooms Type of Heat Purchase Price$ Replacement Unit?(Yes/No) Installer Name Certification No. NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 120 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the information provided is accurate and grants employees of Mason County access to the above described property and structures for review and inspection of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that 1 am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance requirements for which this permit Is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without fast obtaining shall be done in conformance therewith. No changes shah be made without approval. � - first obtaining approval JC,A, 1��• Date o X Date FOR OFFICIAL.USE BEYON THIS POINT Accepted by Date Sub itt mount Due Receipt No. '..t)E .T ..................3.I A ,R Vl>s!ff RO GCIVL3ITC4V CQ{7ES: Building Department 4 Occ Grou Type Constr. Planning Department _ , /?^— yu j; Environmental Health Department N l s Public Works Department {i I Fire Marshal ValuationIV IS BRA i S Building Permit Fee Site Inspection Plan Review Fee EH Review Fee Plumbing&Base Fee Planning Review Fee Mechanical&Base Fee Other Wood/Gas/Pellet Stove Fee State Fee Violation Fee Pre-Paid at Submittal It ) s " TOTAL FEES x' z•} �rt�' FORM MUST BE COMPLETED IN INK PERMIT NO.: PLEASE PRESS HARD MASON COUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA $8684 Shelton 60 27-9670 Belfair 60 276-4487 Elena 60 -6269 Seattle 06 64.6968 APPLICANT INFORMATION CONTRACTOR INFORMATION �,r Owner 'tTm/�� cmrMi� Contractor Name �'1�71t� Co /1zw-y1zD Mail'n Address L tr) Mailing Address Cult AA.) State jg23 Zip Code i City. State Zip Code Phone('3�)k92-I?Y33 Other Ph.(4460)30 8_ Ph.(_) Other Ph.(_, UenMt►e Holder Contractor Reg.# Address Expiration / ! SEPTIC INFORMATION-Connect to New Septic Existing Septic onnect to Sewer System Name of Sewer System PARCEL INFORMAT ON-12 digit Tax Parcel No. / O Fire District Z_ Legal Description /E —IVAc Site Address(Please include street name,street number and city) _ate GAV, v Directions to site Is your property within 200'of the following:Body of Water(Name) 14#4411=AI A4A7 Saltwater Lake_River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs s Rr Sr TYPE OF JOB New_K Add Alt Repair Other Use of Building Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type:Electric Type of Fixture No.of Fixtures Fees. LPG] _Natural Gas Heatpump Toilets Type of Unit No.of Units Fees Bath Basins Furnace Bath Tubs Heatpumps Showers �_ Vent Fans Water Heater / Propane Tank t Laundry Wsher Gas Outlets I Sinks T Wood/Gas/Pellet Stove_L Dishwasher 1_ Direct Vent? FS Other Other Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL i A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT. 1 NOTICE:THIS PERMIT BECOMES NULL i VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 190 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION.The owner or agent on ownees behalf,represents that the information provided Is accurate and grants employees of Mason County access to the above described property and structures for review and Inspection of this project.Acknowledgment of such Is by signature below: OWNER AFFIDAVIT-1 certify that 1 am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance requirements for which 9"permit is issued and that at work will be done in requirements regulating the work for which this permit is issued and at work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No charges shall be made without approval, first obtaining approval. X0 Date 06 X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. )�f Building DpaAnwn Occ Group Type Constr. Planning Department Other Other Permit Fee Ste Inspection Plan Review Fee UFC Plan Review Fee Plumbing 8 Base Fee 00W Mechanical&Base Fee Other Wood/Gas/Petat Stove Fee Pre-Pail at Submittal ( ) Violation Fee TOTAL FEES FORM MUST BE COMPLETED IN INK PERMIT NO. PLEASE PRESS HARD MASON COUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar• P.O.Box 186, Shelton,WA 98584 Shelton (360) 427-9670•Belfair(360) 275-4467• Elma(360) 482-5269 On the web www.co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner JQr&"V ^ IM Y W�� Company Name Mailing Ad ress�� f3�x 2.3-71 Mailing Address City tate Zip Code 9 x''22 S City State Zip Code Phone 4275-` 4r"'36/ Other Ph. Phone Other Ph. Lien/Title Holder Contractor Reg.4 Exp. E mail address 0"k, PAAcr-cd / J &9`Ale- C,001 E Mail Address Drivers Lic.# e(A 9 DOB l! Drivers Lic.# DOB SEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION- 12 Digit Parcel No. Fire District Legal Description Site Address (Please include street name, street number and city) Directions to site 3 Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff—Stream—Slopes or Bluffs J 15% TYPE OF JOB - New Add Alt Repair Other Use of Building Location of Fixtures/Units- 1 st Floor 2nd Floor Basement Garage—Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Type of Fixture No. of Fixtures Fees Fuel Type:Electric— LPG— Natural Gas— Heat Pump_ Toilets Type of Unit No. F Bathroom Sink Furnace Bath Tubs Heatpumps Showers Spot Vent Fan Water Heater Propane Tank Clothes Washer Gas Outlets Kithen Sinks Wood/Gas/PelletStove Dishwasher Kitchen Exhaust Hood Hosebibs Dryer Vent Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICALjj'j�� OWNER/BULDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. X Date: Owner/Owners Representative/Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# Date Bld Pd Receipt No. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ Group-Tyge Constr.- Planning Constr.- Planning Department Environmental Health Department FEES Plumbing& Base Fee Site Inspection Mechanical& Base fee UFC Plan Review Fee i Wood/Gas/Pellet Stove Fee Other Violation Fee TOTAL FEES FORM MUST BE COMPLETED IN INK PERMIT NO.: PLEASE PRESS HARD MASON COUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.CedarlP.O.Box ltiii,Shelton,WA 98684 Shelton 60 27-9670 Belfafr 60 276 Elms 60 a269 Seattle(20614644968 APPLICANT INFORMATION CONTRACTOR INFORMATION Owner K 4 TewaT. C.td fW lyJ Contractor Name �riiYl--n e Dt�►t`�z.T►�� Mail n Address L Mailing Address City N stateld.6 Zip Code City State Zip Code Phone(13%k0g t692• 33 Other Ph.(3foo) C Ph.(__, Other Ph.( UenMtle Holder r Contractor Reg.0Address _ Expiration / / SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMAT ON-12 digit Tax Parcel No. 1 D Fire District 2_ Legal Description Site Address(Please include street liame,street number and city) Directions to site 3AF4 -'t Is your property within 200'of the following:Body of Water(Name) _Saltwater Lake__River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs j TYPE OF JOB New Add Alt Repair Other Use of Building R.-Si Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet I PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type:Electric Type of Fixture No.of Fixtures Fees • LPG Natural Gas Heatpump Toilets Type of Unit No.of Units Fees Bath Basins Furnace Bath Tubs Z Heatpumps Showers �_ Vent Fans Water Heater / Propane Tank t _ Laundry Wsher-- Gas Outlets Sinks Wood/Gas/Pellet Stove Dishwasher �_ Direct Vent?y& Other Other Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTUREIUNIT. NOTICE: THIS PERMIT BECOMES NULL i VOW IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 190 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION.The owner or agent on owner's behalt,represents that the Information provided Is accurate and grants employees of Mason County access to the above described property and structures for review and Inspection of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a Contractor Registration Law RCW 18.27 and am aware of the ordnance contractor in the State of Washington and that 1 am aware of the ordinance wNirernents for which this permk is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without approval first obtaining approval. X� Dab _C Q�T X Dale FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. i Building Department Oee Group Type constr. Planning Department Other Other !ta n. .. t. S6a I < Permit Fee nspe�on Plan Review Fee UFC Plan Review Fee Plumbing 3 Bass Fee Other Mechrtcal 3 Bee Fee Other I Woodl.&IPe6at Stove Fee Pre-Paid at Submittal Violation Fee TOTAL FEES 1 i FORM MUST 13E COMPLETED IN INK PERMIT NO.: PLEASE PRESS HARD MASON COUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.CedadP.O.Box 186,Shelton,WA 92684 Shelton 60 27-9670 Belfair 60 27"67 Elms 60 -6269 Seattle 06 4968 APPLICANT INFORMATION CONTRACTOR INFORMATION Owner K A-rein>; AA4cc,64UivvJ Contractor Name Mall'n�Addressl-ez � L. W_ Mailing Address CityState Zip Code City State Zip Code Phone3 Other Ph.( 3(00)�0 Ph.( Other Ph.0 Lien/Tltle Holder Contractor Reg.# Address _ Expiration SEPTIC INFORMATION-Connect to New Septic Existing Septic _ A—Connect to Sewer System Name of Sewer System PARCEL INFORMAT ON-12 digit Tax Parcel No. / D10004CW I Fire District 2- Legal Description -MA-c Site Address(Please include street name,street numb r d city) IUAC AV. P Directions to site Is your property within 200'of the following:Body of Water(Name) h,f✓'4115,y I-AA7-= Saltwater Lake__River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JOB New Add Alt Repair Other Use of Building as ` Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type:Electric Tvoe of Fixture No.of Fixtures Fees LPG_X._Natural Gas Heatpump Toilets _9_ Type of Unit No,of Units Fees Bath Basins Furnace Bath Tubs Z Heatpumps Showers 1_ Vent Fans Water Heater / Propane Tank _ f Laundry Wsher-7— Gas Outlets Sinks � Wood/Gas/Pellet Stove_ f Dishwasher Direct Vent?y6EE Other Other Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT. NOTICE: THIS PERMIT BECOMES NULL i VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION.The owner or agent on owner's behaff,represents that the information provided Is accurate and grants employees of Mason County access to the above described property and structures for review and inspection of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a Contractor Regl"on Law RCW 18.27 and am aware of the ordnance contractor in the State of Wasttrgton and that I am aware of the wdimnee requirements for which this permit is issued and that a8 work wit be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without rust obtaining shall be done in conformance therewith. No changes shall be made without approval. first obtaining approval. X0 Date 0`-:) X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by -Date Submittal Amount Due Receipt No. Building Department Occ Group Type Constr. Planning Department Other Other Permit Fee Site inspection Plan Review Fee UFC Plan Review Fee Pkanbkng E Base Fee Other Mechanical 3 Base Fee Other WoodrGasli'det Stove Fee Pre-Paid at Submittal ( ) Violation Fee TOTAL FEES 4 MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT WSEC/VIAQ Compliance 4pplication Owner:MARI< Telephone: c z b Parcel#: n—SO-0000g Type of project f New Residence ( )Ad i ( emodel Total Sq. Ft. t q,.,,i 1$ Floo+. O� 2" floor: 2 700 Heated Basement: of heated area.. Heating System Type: XEiectric wall heater O Electric Central Fur"bWl.FilZ9 &T O Heat Pump with electric furnace O Heat pump with gas furnace O Boiler, specify fuel type: O Other: Specify Glazing Prescriptive Option see reverse side circle one: 1 11 IV Percentage: Compliance Method O Component Performance , Chapter 5— Calculation Worksheets required a 3 % Check one:: O Systems analysis, Chapter 4 lor Whole House Ventilat OWhole House Ventilation using a Heat Ventilation using exhaust fans&window or wall fresh air System vents (VIAQ 303.4.1) Recovery Ventilation System (VIAQ 303.4.4) Check one O Whole House Ventilation Integrated O Whole House Ventilation using an inline with a Forced Air System (VIAQ 303.4.2) 1 supply fan. VIAQ 303.4.3) Window & Door Schedule (If needed, attach an additional sheet) Total Manufacturer Room/location U-Factor Size Quantity Square Feet Windows: Windows: Total Sq. ft. Doors: Doors: Total Sq. Ft Total window and door area Total window&door area 7JT .g /(divided by)total sq.ft of heated area 1911 = o?3 %of glazing Oo � Z Ro a U@ADH � _ Z D Q � CD CO O° < c o� R CE V E o o CD 426 W. CEGAZ Sf o � CR a. o, � r �l7 v+ � $�- �, o p o CD 77- CD 7 c9 vr� ICl �5on • OCD ram+ o 0 1 o v J n —a = CD E C7 NE Haven Way =� t r E —' o ao CD co 0o 0o o n r O°`< c v- r o N CCD CD O ---i cn o ,1 0 0 0 0 00 00 'tot ExIsr Dann Field Reserve Drain Field 7� n T 15x25' 15xw C E � Av50, m K Proposed Residence Floft ` Iff rC zr � zv, F r o � o f Y Mason County Permit Assistance Center Planning Intake Checklist Owners Name: Yl4c C Date: -4 0 Project: IS T Reviewed By: Commercial Development: YES O Comments: Planner: GBM TSC Site Plan: PLARNiNGR ECEIVEp North Arrow Property Dimensions: S'0' x a 1 APR 2 21005 Streets.and Driveways Shown.Road name: q v�t,,, tJ4WW,. ?All Existing Structures shown with setbacksSTA, p( Well Location, Septic and Drain-field Shown with setbacks Identify all surface water(streams,ponds, shoreline,wetlands, etc.) Topography(slopes) Proposed Structure Setbacks(Direction/Setback): F:L/_F4 -R:S// S 1: IV / � r S2: Utility and Drainage Easements: Yes Z9ji7Xif yes enter condition#5022) Other Easements Accessory Appurtenances u County Access Permit Needed(add condition#0010) o State Access Permit Needed(add condition#0020) Standard Conditions to be added to all Building permits that planning reviews:#5019 and#0700 Are there any impediments that may restrict access to your site? (dogs/gates) Shoreline and Planning Info Setbacks: Shoreline: Slope: Shoreline Designation: Comprehensive Plan: Rural Zoning: ❑ Not Applicable ❑ Agricultural J2<RR 2.5 .� 20 CK_Urban ❑ In holding O RW ❑ Rural ❑ LTCFL ❑ RC -1 2 3 ❑ Conservancy Rural ❑ RI ❑ Natural ❑ RAC ❑ RNR ❑ Unknown ❑ RCC-Hamlet ❑ RT ❑ Urban Growth Area ❑ WR O Unknown O Unknown Water Body( e of water if unnamed): SEPA:Y s No o FUInown Flood Plain: YES N apAquifer Recharge: YES N Map# Tags/Cases: RLC/SPI Case: 6-Year Dev.Moratorium: YES NO Eagle Nest Tag: YE NO Other YES NO Addressing: Check box if needed ❑ Reviewed by: Revised:02-04-2005 IVI ANNINOCHARELL&RENEMPLANNING INTAKE MASON COUNTY DEPARTMENT OF HEALTH SERVICES Environmental Health - Personal Health PO BOX N,WA 98584 ENVIRONMENTAL ��tOC ( 27-9670 75-4467 Application for Dki AAiT*loon of Adequacy FAX(3s 798 Q26 CED Instructions 1. Complete Part 1. No determination can be made until Part 1 is fully completed. 2. Complete only,the portion of Part 2 applying to the type of water system utilized. 3. Submit completed applicationwith attachments to the health department for review. PART 1: Applicant/Parcel Identification Name of Applicant N1ARVc g`T'q-kaz cmJ3 6 t1AJ Date c?1 Ar-,2 0 S Mailing Address 919 3 1,64 4v PL kid Telephone, 692-W3 3 W, . w . 7S- goS-V6 11 P4?rV? Assessor's Parcel Number 2 2 33 0 -S'o-D©o0 8 Type of Water System (Check One): Reason for Application (Check One): I ❑ Public/community water system(2 or more connections) Building permit ' Individual well(one connection) ❑ Land use application,if so... Well ❑ Division of land ❑ Spring/surface water #of parcels? ❑ Other(explain) SPH2 - ❑ Boundary line adjustment ❑ Other(explain) i z PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adequacy: Public Water System Name of Water System Water Facility Inventory(WFI)Number. ❑ The water purveyor has filed a letter granting blanket hookups to this water system. ❑ 1 am the manager of this water system. The water system has been approved for services. There are presently connections in use. This will be the connection. 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 state and local regulation. z Signature of Water System Manager Date Update:March 22,1999 a INS Individual Water Well Water well report(attach to application) Depth I SS ft. Well capacity test(attach to application) 11• gpm End The well driller often performs well capacity tests at the time the well is contracted Test results from these tests are noted on the water well repoK. Results hom these tests will be accepted !f the water well report cannot be located by the applicant or if tie water well report does not have a capacity test, a well capacity test, which provides stabilization of drawdown and recovery data, must be performed by a licensed contractor. FXSatisfactory bacteriological test(aaach to apphcabm) Individual Spring/Surface Water ❑ WDOE WR permit(attach to application) ❑ Method of Disinfection ❑ I have reason to believe that this water source can provide at least 800 gallons per day and/or provides water at a rate of 2 gallons per minute based on the following observations Author of Statement Date Relationship to applicant In addition to providing the above statement,the applicant will need to arrange an on-site inspection by the health department prior to determination of adequacy. Departmental use only. Do not write below this line. PART 3: Health, Department Evaluation (staff use ontyl 0 SATISFACTORY DETERMINATIONS Applicant's water supply appears.adequate to Meet the needs of its in d use. This determination does not address adequacy of the distribution system,guarantee an adequate supply of water indefinitely into the future or guarantee compliance with all applicable WD©E water resource regulations. 0 UNSATISFACTORY DETERMINATION.Applicant's water supply does not appear adequate to meet the needs of its intended use fur the following reason(s): REVIEWER'S SIGNATURE DATE Update:March 22,1999