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Home My WebLink AboutBLD Water Adequacy - 5/12/2003 05/14/NO3 09:52 3608776713 LCMC PAGE 02 m crow � . i��-e' nu uviiwe sun N0.644 P.2/2 MASON COUNTY DEPARTMENT OF HEALTH SERVICES smbommewd Heaiak Pesaad Xedrh to BOX t666 S MIM.WA 90 4 LOCAL 06M 427-%70 BWAM(360)275-"67 de 4"11 Application for Determination of Adequacy Inrtructianr PART 1: Applicant/Parcel Identification Nerve of Applicant `14.t-�t b a��---- Due MailiagAddre" k`di MtLr w'F Tclephone ).1r3 -Q 244. / ar Y Assessor's Parcel Numbs ya 101 Tygc of Waler System heck Ong . Agason fof Applicaftn Check Ong : { PnblidCoaimuoity Water System(2orMarc 13uiWingpermit eameeeo.e) o Lod use applioadee,Ifso,. C Individual water sauroe(oss=mcct)K-iif10- p Division of band c well #of Percale? o SprhtS wboewuw SPH9 v p&c(eq ) o Boundary We Austmem v Other(mtP�) J PART 2: Water System InfOrnistiOn Complete the section appropriate for the type of water system being evdusted for adegltaey: Dublin Water 8 stem ama of water system 4 k11A man Water .Faaititr laveatory(WFi)Number: G The water purvrjw less toed a letter X.xn8na bbeket hcokoPs m*b Warne syseem. + a Iamtitsmsaa` of*awavereyae� 2ha water systama oa ��ovedtar eavices hemaro eeeaeayoae in use, 9:WN tm the wnnatieo.,A"We Mtaet is abk and am�Asa" less)eomteedans sxeeedina the lkmn of dw water system at ay 'sig amm of Wets system Manager rl,IWIIlr/ WlTAXAM.arr llvdms Me*U Is" w - 7 MASON COUNTY DEPARTMENT OF HEALTH SERVICES _ Environmental Health - Personal Health PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 BELFAIR(360)275-4467 Application for Determination of Adequacy FAX(360)427-7798 Instructions tte �e,prefn,at2bothe " u : F3, Submit completed application,with attachments to dieheahh department for review. PART 1: Applicant/Parcel Identification Name of Applicant --1%M l�1 & LI S! Date -0 40 Mailing Address wAi Telephone -a / gotic ` Y3 2T:& — re00 WOO- Assessor's Parcel Number q aA09 so 0 0O S-y Type of Water System (Check One): Reason for Application (Check One): 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) 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. iT5 s water system is able and willing tome water to this(these)connections wa outfit exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date Update:March 22,1999 .arm If Individual Water Well LOSMa Water well report(attach to application) Depth ft. Well capacity test(attach to application) gpm apd we er n pe orms we ity tests at time we is construct est resu is m Mae tests are noted on the water well report. Results from these tests will be accepted. Ifthe water well report cannot be located yy the aQplicant or if the water well report does not have a capacity test, a well capacity test, which provufer stabilization of drawdown and recovery data, must be rmed a licensed contractor. tisfactory bacteriological test(attach te application) Individual Spring/Surface Water u WDOE WR pertnit(attach to application) u Method of Disinfection u 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. MGM? . s y Ion . . Update:March 22,19" MAR-29-2006 WED 08:33 AM LAKE, CUSHMAM. MAINTENAMCE 3608776713 P. 02 MA50N COUNTY DEPARTMENT OF HEALTH 5ERVICES Environmental Health Personal Heakh PO BOX 1666 SIdEL.TON,WA 99594 LOCAL(360)427-9670 BELFAM(360)275-4467&4468 Application for Determination of Adequacy Instructions MEn M 1 ? PART 1: Applicant/Parcel Identification Name of Applicant ,Tim 1 11 i O n Date 6.1 acd p p Mailing Address I . Telephone Z53-922LZ4LII Assessor's Parcel Number 9 2 a.09 0000 5i LI Type 9f Water System Check One : Reason or Application Check One Public/Community Water System(2 or mom Building permit wnwetiam) ❑ Land use application,if so.. ❑ Individual water source(one wmrcdon),if so.. a Division of land ❑ Well #of Parcels? ❑ Spring/surface water sPF19_ ❑ 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: o 353,9 O ❑ The water purveyor has filed a letter granting blanket hookups to this water system. ➢( I am the maim a of this water system The water system has been approved for J�a services. 'There are presently connections m use. This will be the connection. This system is able and willing to prove a water to this (these)connections wr out exceeding the limits of the water system or any limits set by state and local regulation. efWater q femn t2ci'7 Date b ,Signature of Water stem Manager H.IWDAYAURCUlYMWA7BR1D3.WP Updat=Much 22,109 w - 7 03/29/2006 WED 8: 40 [JOB a0. 50471 0002 MAR-29-2006 WED 08:33 AM LAKE, CUSHMAM. MAINTENAMCE 3608776713 P. 01 LAKE CUSHMAN MAINTENANCE COMPANY FACSIMILE TRANSMITTAL SHEET PROM: TO: Trish Woolen Julie A.MLGGrady DATR: COMPANY: 3/29/2006 TOTALNO.OP PAGES INCLUDING COVER: PAB NUMBER 2 -4`7.8442 T;ONB NUMBER: 66NDE Ca1lU RHPBABNCE NUTW BR lson YOUR RgIr♦IWSNCE NUMBER R8' Water Adequacy ❑URGENT Rl FOR REVIEW 0 PLEASE COMMENT ❑PLEASE REPLY ❑PLEASE RECYCLE NOTES/COMMENTS: Sending Water Adequacy Per Jim CaUison's request (CLICK BERB AND TYPE RETURN ADDRESS] 03/29/2006 WED 8: 40 [JOB NO. 50471 ®OOt