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Home My WebLink AboutBLD Water Adequacy - 7/17/1995 MASON COUNTY DEPARTMENT OF HEALTH SERVICES E : - POST OFFICE BOX 1666 (y SHELTON, WA 98584 1` J�JL18199� (206) 427-9670 FAX 427-8425 aENERA��_Rvl„tlg ICATION FOR DETERMINATION OF ADEQUACY -` Revised 09/01/92 INSTRUCTIONS 1. complete Part I. 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 application, with attachments to the health department for review. PART 1: APPLICANT/PARCEL IDENTIFICATION __ _ ?a?i —!a=??i°-?!ai ?!a??i i i1?iis iii 1 i i!}z ii aii ii a:ii - ?!aa —!ia p NAME OF APPLICANT 1n.n r_a i L. Crock-e-c DATE !'1 7"/Js- �� MAILING ADDRESS u7aa '231 A%JE SE; TELEPHONE (20(0 ) 33 i-1 -6273 Z- CHI 2ssQguah WA 98D.Z7 (ZO6) 8 (W� C 1ty etet� s 3'ot' 13(0 - 14 - c)C070 21 N 3W 3(0 SE-Y4(?) ASSESSOR'S PARCEL NUMBERat==- SUBDIVISION (If Applicable) LOT TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) El Public/Community Water System Building Permit, Single Family Res Individual System, Drilled Well Building Permit, commercial Individual System, Dug Well El Building Permit, Replace/Remodel Individual System, Spring Land Use Application Name Individual System, Surface Water Type El Individual System, Other ❑ Other PART 2-A: PUBLIC WATER SYSTEM NAME OF WATER SYSTEM WFI ID The water purveyor for this system has previously filed a certificate of water adequacy with the health district. I am manager of the above referenced water system. The water system has DOH approval for __ service connections, with _ connections presently in use. The applicant has approval to connect to this water system. Service of water to the applicant for domestic purposes is consistent with both the water system plan and the water right permit presently in effect. water lines are available to the applicant's property line, or the applicant has made satisfactory arrangements to extend the lines. DATE SIGNATURE OF SYSTEM MANAGER W-7 PART 2-B: INDIVIDUAL WELL i7l3HlfliE3513E3E37733773577iii l!lli k7Eip1k33333€7t3l313111f33 i5l53f111lE3tt lillitlt lilitlllll lllf!!klll3Enlit715 3 5 7 5 3 3 11111111i11111111111111111111111111111173tl53fl 111111111 I WELL DEPTH � � p Ft WELL CAPACITY .20 GPM Gallons/Minute Gallons/Day ell log is attached to this application Wf* Well capacity test results are attached to this application NOTES: Well capacity tests are often performed by the well driller at the time the well is con- structed. Test results from these tests are noted on the well log. Results from these tests will be accepted by the health department. If a well log cannot be located by the applicant, a well capacity test must be performed by a licensed contractor. Baler or pump taste are acceptable, provided stabilization of draw-down has been measured and recorded. Satisfactory total coliform test is attached to this application. PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER - - }:1}l ii i'iii:Fiii}i E ii iii Fi Ei]ij li!}Ij}'x iiai€i€:is[f iill l?li iiii€3€i€Ili}}It}}}71€1}]}1}iiii€E€€i7 iE li 17}13i li i§ is ill 11. .Ili.li€Ili€ii€€i€€ii€ii ii ii...li l3l l 'g i€1€1[€i WDOE permit is attached to this application I have reason to believe the spring proposed as the water source will supply adequate water its intended purpose. This belief is based on the following observations: 9 s S 's AUTHOR OF STATEMENT DATE 1 1 RELATIONSHIP TO APPLICANT NOTE: In addition to providing the above statement, the applicant will need to arrange an on-site inspection by the health district prior to determination of adequacy. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) !}€ €€ii:Ili Y.I i}€€€ e , . ,,. - •eye ,Fi•u e.e::" "!" is €3€€€€€iii,'•• 1 : I !i €€'€€€'3i`i se r-u sa:::'ni i}}:}:,S'€ - €iuia ustutP•e":;.`,3:..:..€3 i..."a u:uuiuu ueu se utn•••-its.'€s: isFUFee ee u.€€€.€€.[_:! ;.:,:::..i.."'r...€i€:. ... SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet needs of its intended use. Note: 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 WDOE water resource regu- lations. UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade— quate to meet needs of its intended use for the following reason(s) - HEALTH INSPECTOR DATE Rev' '0101/92 MASON COUNTY DEPARTMENT OF HEALTH SERVICES Errvbnmaatta/Hedth Peraaiml Health PO BOX 16"SIIELTON,WA 98584 LOCAL(360)427-%70 BELFAIR(360)275-467&4468 Application for Determination of Adequacy Instructions L Applicant/Parcel Identification Name of Applicant 1)�( � C�ky- MiA��i oL K Date Mailing Address 90E, Eff,e�Frosser Telephone y3a-1a67 SheR&K iF RgSsl Assessor's Parcel Number 3a 13& 14 90070 4 e o Water stem Check One): Reason for Appacadon Check One): 0 PublidCommunity Water System(2 or more Building permit 10 eonnectim) o Land use application,if so.. Individual water source(one comieww),if so.. 0 Division of land Well #of Parcels? o Spring/surface water SPH9_ a Other(explain) 0 Boundary line adjustment o Other(explain) PART 2: Water Sys em 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. 0 The water purveyor has filed a letter granting blanket hookups to this water system. 0 1 am the manager of this water system. The water system has been approved for services. The connections use. This will be the c�aecilm-7 eta system is able and willin am FWang yto in provtW water to this(these)connections wt out exceeding the limits of the water system or any limits set by state and local reguMon. Signature of Water System Manager Date H:IWDATAURCHIMWATMD3.WP Update:March 22,19" W - 7 3 : Individual Water WeU l n Wow well report(attach to application) Depth & o Well capacity test(attach to application) Spin and A j Well tty tests are often performed by the well driller at the time the well is constructed Test 3 results these tests are noted on the water well report. Results from these tests will be accepted Ydw water well report cannot be located by the applicant or ry/''the water well report does not have a capacity tuR a well capacity test, which provides stabilizat on ofdraw-down and recovery data, 3 must be performed by a licensed conductor. o Satisfactory bacteriological test(attach to application) i IndrviduqlSpringlSurface Water o WDOE permit(attach to application) o Method of disinfection jI o I have reason to believe that this water source can provide at least 900 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 1 s. 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 s Departmental use only. Do not,write below this line. hh:b; _ t8 orr# r fi ESa r i 3syat� 'r t''t� �+ , ro �+Fr 31i*QFi+F � XI s %4. Pi '' `:>�, '3A'•��rll'�(JiiQnS 4. t .. s 3 m4' dIM III H.-IWDAT. WRChVVE1WATMD3.WP Update:Much 22,1999