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Home My WebLink AboutBLD Water Adequacy - 8/24/1992 MASON CQUNTY DEPARTMENT OF HEALTH SERVICES i POST OFFICE 8 , SHELTONNs FAX 44 -9425 APPLICATION FOR DETERMINATION OF ADEQUACY INSTRUCTIONS 1. Complete Bart 1. No determination can be made until Part 1 is faY cos�leted. 2. Ccmpieto only the portion of Part 2 applpinq't 110 the type Of water system utilizad' 3. Submit completed application, with attaohftftts to the health department for review. PART 1 AIIPLICANT/PARCEL IDENTIFICATION 'AtIIItliittt0ttttlH#11111i11i#tt111till!❑itl11111#tllllt#IIIt1Ut11tIllllilit1111f118ilitllflltltliiltliilfltillitlUllilili1tt111i11�1#iytillittil11111fftiHitt{iifitl[tl _ !IAMB O!"APPLICANT R C/V4 e- L7oT P/ DATE MAILINti:ADDRESS _LO 1(3 US /7 V �O� TELEPHONE r 2nC 1 . a 16M e ASSEBAW S PARCEL NUMBER SitBDI j Applicable) llyislily TAT TYPB'or-WATEn'SYSTBM (check One) REASON !OR ApPLicATiON (Check One)_ (('` Public/Community water System n Building Permit, Single Family I` 0 Individual System, Drilled Well 0 Building Permit, COMN=ial Building Permit, Replaco/Reswel :Individual System, Dug W011 0 Individual System, spring � Land Use Application Rams : Individual system, Surface Walter Type Q individual System, Other ® Other ec a lo' va l fdA Aor !jolts fiom ase. PAR`3' 2-At PUBLIC WATBIt SYSTEM itl1111fltt{41111114!iltitit#Ist.t ! !!##ittllli'Itl##t€Ilitilitlltl#itli!l11 hilt#hi'IlltYli#lliill#11i41111Hliilltll[l#1!1#1#Ilillll#111It#IBlllllll1111lift 111111111111ft1 NAM OF WATER SYSTEM S Ake: `D^ImKnl # ✓ I ID Us Water purveyor for this.system has Preciously filed A oertitfaito of Water adsgsary wllm the ttes2th yt..district.. I am "Roger of the above refs.-anted Water system.. no water s"tas Ms am "Prwal tat am+lma : connections, vita MA connections Presently in use. 2Mt.applieast No approval to aosgidh' Qis WatfC :system. Service at Water to the APplicant for doemstia purposem to edeautemt wilts boo the w"*ay►'ws :.. . pica me the weer right vomit presently is effect. :water luo are*W41 Ole to-...as appliGmt"s pidpsrty line.-or the applicant has tintactory arrangements arrest tpia usam. ,.. P.asA:t N or sysrmt l PART, 2-R: INDIVIDUAL WELL llfi�ltlitnitllillt11n131UIi7lllllililllliilil111111Ul1tlUHlHntrtInnitDlitllilt��flilitilfil111l11IIltintlMllifilflilNlninfdilfllniifiHti!lNlfnnN71ll7111` WELL DEPTH Ft WELL CAPACITY Gallons/arimrte Galloeis/Day.. well log is attached to this application o well capacity test results are attached to this application MOM: wall capacity tests m often performed by the sell driller at the time the sell im constructed. Test results from thew tests are noted on the wall lay. saapits in% these tens Will be accepted by the health department. If a :cell J." Osman to leaned WAIL t, applicant, a Wall capacity test wet be performed by a licensed osaamw. ]!ales or yasr., ' tests are acceptable, provided stabilisation of dreWdown bes belt *yard aed favors". Satisfactory total coliform test is attached to this application.' PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER Inulrinialf111]1111111111 fill uuunttlnnlfuutNiiuulmluwnnllmll��ulnduttinmi(ltenon�t�nnninnutllnnunFdmirnntanfinarll �f 0 WDOE permit is attached to this application y ` I have reason to believe the spring , proposed , as the water source will supply adequate water its intended purpose. This belief is be*" on the following observations: AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT NOT to addition to providing the .bee natarnt, the applicant Will us" to nVnse as on-alto inspection by the health district prior to determination or adequacy. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) uluafrnlf7nnunnunmlulf luunfnnti►1nnn1111!l111111F1tllllrlllululmumf uDllltnuuuflDuuunnfiufnlrufnnnf►nnnfrfaulalNlturnfN 0 SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet needs of its intended use. -. Rau: This datermianlem does net address adequacy of the distribatlsb $yetim,1retantea at edpwte ttpply Of water indefinitely into the future, ar guarestes copilaone Wits Oil appilmple imam se$K meamesme tpa• lations. 0 UNSATISFACTORY DETERMINATION: Applicant's water ripply does not appear ads- quate to meet needs of its intended use for the following reason( ): HEALTH INSPECTOR DATE - MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY Revised 09/01/92 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 application, with attachments to the health department for review. PART 1: APPLICANT/PARCEL IDENTIFICATION 6i333i:i i i3333li i 3333333ii33ill333333333i33333i ii 333333333333i3333133333311(3n13(33 iti3i 1333ii3333311 i 333iiii3133i333333i33.,uu..t t::,,:n u,:3J33i3:.,ii3L x,t.i:.i33.:,::a NAME OF APPLICANT to la PJl� �'e DATE -G 3 MAILING ADDRESS 10 ( TELEPHONE (-i.a ) 5 33 n r>SxMt p lA'X,xS �7 C1CY et�t� D ASSESSOR'S PARCEL NUMBER SUBDIVISION (If Applicable) LOT TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) Public/Community water System 0 Building Permit, Single Family Res Individual System, Drilled Well Building Permit, Commercial ❑ Individual System, Dug Well Building Permit, Replace/Remodel Individual System, Spring Land Use Application Name Individual System, Surface Water Type Individual System, Other Other PART 2-A: PUBLIC WATER SYSTEM 3333333333H33 III 3633III 1111111111111111111111111111111111 3pppppipppip0t1133333333333 III 3333333333333ppp 3p 3 313 It 1111111111 3 3131ppippp3pi111111111131111❑ NAME OFATER SYSTEM S64A. 1�F- ��'�''m�-v; OtL b wFI ID O UIZ() St The water purveyor for this syate he previously filed a certificate of water adequacy with the health district. EI e manager of the above raferanced water system. The Water "ate ham DGa approval for�j-p X?- service connections, with 6 S connections presently in use. The applicant he approval to connect to this water system. 9srvice of water to the applicant for domestic purposes is consistent with both the watsr syste plan and the water right permit presently in of fact. water lines are available to the applicant •a property line, or the applicant has made�satisfactory arrangements .to extend the lines. L� c 9IGNa1VRE OF SYSTEM 3M3mGIM �— C-7 PART 2-B: INDIVIDUAL WELL !i!llitlli ll 111113 is 11l 111 lil l Itll!!Itl111!!!!!!!!I!l171l111l11!lltl ii ltti illlll li lil 111 111 111 it if I11111l III III II111111111111111l11l11lI111l I I111111IIII II II II II II II IIi Ill it l! WELL DEPTH Ft WELL CAPACITY Gallons/Minute Gallons/Day Well log is attached to this application Well capacity test results are attached to this application NMS: 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 Iran 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. Haler or pump tests are acceptable, provided stabilization of draw-dawn has been measured and recorded. Satisfactory total coliform test is attached to this application. PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER 1!{{!!!il•''Il it ii llill ii l i{i7{1173111777{IIi IIIl ill It it ll ill il7ll llll it ll{Illi13!{II1{1i17111i 1111l11133317t7!❑71{{ii711hl113 t7{713{!3l373333 i7{!{{{7R17 i7 is Rl7 t713 ill I l![! WDOE permit is attached to this application I have reason tiO believe the spring proposed as the water source will supply adequate water its intended purpose. This belief is based on the following observations: AUTHOR OF STATEMENT - DATE RELATIONSHIP TO APPLICANT y 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) i71111!l331t i1 illlllllill ll li lli lilt ll llllllltlll iltli ll ll 111 lllllllll llllll llllllltlllilll7I111111111lIII IIia lilili itil iiitilli!!{IIII Iiillilll i111Iii1111 illliill ilttllltltl 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 systsm, guarantee an adequate supply of water indefinitely into the future, or guarantee compliance with all applicable wmz water =an== regu- lations. EJ 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 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY Revised 09/01/92 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 application, with attachments to the health department for review. PART 1: APPLICANTRARCEL IDENTIFICATION -__----------;ii_1Hi _....!—,.•...-:.•..a::;:;E:;a =iE ........ •......:a:33,. _________ _ : ,_ ,_ _ - F:;:E:E:F:_;_:_i_i_i_Ea_E_:_i F:ii;:i i..... 3 i ?• Ei--xi-a--3E i:_i_:_i: ,,,,a ,za, •z-x •""°- °v izi ii:: _ -air-x va• iei_ _ _ • •x• e.ii ii is ii ii ii'- -i xxx•ax•a,aa„•z.aax.ax•.a...a.x/•nl.. -34 zi:a x,a:i::::::v::: NAME OF APPLICANT DATE Q� 1�LO I,/ DATE MAILING ADDRESS (,€ � 9'.`�C) Sf-ct� �/� . DQ� TELEPHONE (36&) IFlp"n rya cis / Mess. C Sty 9G�t� Elg ASSESSOR'S PARCEL NUMBER S/9 AA S- ADO - /6-1 _ Qtz- SUBDIVISION (If Applicable) LOT TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) Public/Community Water System Building Permit, Single Family Res Individual System, Drilled Well Building Permit, Commercial Individual System, Dug Well Building Permit, Replace/Remodel Individual System, Spring Land Use Application ❑ Name Individual System, Surface Water Type Individual System, Other El Other PART 2—A: PUBLIC WATER SYSTEM NAME OF WATER SYSTEM 5YOR (3h Po/-1b11//✓/ T `7 CG//13 WFI ID 83 68OF 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 aystem. The water system has DOS approval for f/0 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. q /� SIGNATURE OF SYSTEM MANAGER �L�"'Y�' ✓' _ l DATE /G` 1/ 7 W-7 VHS 0 v Cbee Es��Ir Fir PART 2-B: INDIVIDUAL WELL WELL DEPTH Ft WELL CAPACITY Gallons/Minute Gallons/Day Well log is attached to this application 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 wall capacity test must be performed by a licensed contractor. Baler or pump tests 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 EJ 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: AUTHOR OF STATEMENT DATE 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) 11 IIIIIIIIIIIIIIIIIIIHIIIII I H IIIHII fill III 11111111111111111111111111111111111111111111111]HiIIIIIIIIIIII III II IIIIIIIIIIIIHIIIIIIII IIIIIIII 111111111111111111111111111,1111 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 meource regu- lations. UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade- quate to meet needs of its intended use for the following reason(o) : HEALTH INSPECTOR DATE Revi,', ^,9/01/92