HomeMy WebLinkAboutWater Adequacy - WAT Application MASON COUNTY
DEPARTMENT OF HEALTH SERVICES -wu,
Environmental Health Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy
Instructions
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PART 1: Applicant/Parcel Identification
Name of Applicant 0 A yl F 1r w 12 � Date
Mailing Address S 15 a Telephone N L S 3 7 3 7 8 7-
Assessor's Parcel Number
Type of Water System Check One): Reason orA lication Check One):
❑ Public/Community Water System(2 or more J9 Building permit
connections) ❑ Land use application,if so..
B Individual water source(one connection),if so.. ❑ Division of land
6 Well #of Parcels?
❑ 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 System
Name of Water System
Water Facility Inventory(WFI)Number:
❑ The water purveyor has filed a letter granting blanket hookups to this water system.
❑ I 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.-T hater system is able and
willing to proviCe water to this(these)connections wt ou'Ti eexceeding the limits of the water system or any
limits set by state and local regulation.
Signature of Water System Manager Date
H.•IWDATAURCfflMWATERdD3.WP Update:March 22,1999
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Individual Water Well
10 Water well report(attach to application) Depth.,, ft.
a Well capacity test(attach to application) t/T gpm gpd
Well capacity tests are often performed by the well driller at the time the well is constructed Test
results frrom these tests are noted on the water well report. Results from these tests will be accepted.
If the water well report cannot be located by the applicant or if the water well report does not have
a capacity test, a well capacity test, which provides stabilization of draw-down and recovery data,
must be performed by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application)
Individual S rin /Sur ace Water
❑ WDOE 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.
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H.IWWDATAIARChYVEIWATERAD3.WP Update:March 22,1999