The URL can be used to link to this page

Home My WebLink AboutBLD Water Adequacy - 12/27/2002 4 MASON COUNTY DEPARTMENT OF HEALTH SERVICES Personal,Health Environmekal Health PO BOX 1666 SHELTON WA 98584 LOCAL(360)427-9670 BELFAIR(360)275-4467&4468 Application for Determination of Adequacy Instructions 1 ': Complete Part'I No determmanon can be made until;Part 1 is fiilty comolefed 2 Complete only thepomon of Fart 2 applyyrgto the type of water;system utilized 3 ': Submit chin leteda hcatton:with sttacliinents;tothe health,de " ent for`:revtew. PART 1: Applicant/Parcel Identification Name of Applicant gV?Lj� tiv/ 1 w Date Mailing Address �� E ! 5 I` �✓ ' Telephone 77 lA tB Assessor's Parcel Number —1 Ocq 7D E ba v� t�-- on tJ tit �21zvt� Type of With S stem Clreck One : Reason forA lication Check One pF- Public/Community Water System(2 or more Building permit connections) ❑ Land use application, if so.. ❑ Individual water source(one connection), if so.. ❑ Division of land ❑ 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 S tem Name of Water System Water Facility Inventory (WFI)Number: ❑ The water purveyor has filed a letter granting blanket hookups to this water system. O I am the manger of this water system The water system has n approved for YI services. There are presently (J _connections muse.')This will be the connection."'111TitsTT�water system is able and willing to p—rovtde water to this(these connections wi ut exceeding the limits of the water system or any limits set by state and local regulation. �f Signature of Water System Manager I/VL-, Date �2 H:IWDATAURC19VLIWATERAD3.WP Update:March a 1999 W - 7 r Individual Water Well i ❑ Water well report(attach to application) Depth ft. ❑ Well capacity test(attach to application) gpm _ eod Well capacity tests are often performed by the well driller at the time the well is constructed Test resultsrom 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 o plicant or if the water well report does not have a capacity teit, a:well capacity test, which provi ees stabilization of draw-down and:recovery data, must be performed by a licensed contractor. ❑ Satisfactory bacteriological test(attach to application) Individual SpringlSurface 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. PART 3 Health Department Evaluation (srafjUseonlyJ SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet the needsi.of its intended used This determrnaron Cloes not address adequacy of the d�stnbutton system„guarantee an adequate supply of y4ater mdefinrtely info the future or guarantee compharrce with&11 applrcgble WDOE water resource regulations ❑ UNSATISFACTORY DETERMINATION" Applicant's water'supply does not appear adequate to meet the needs of its intended use for the;followtng reason (s) I REVIEWER'S SIGNATURE < DA K,IWDATAURCN/VDWATERAD3.WP Update:March 22, 1999 MA56N COUNTY X DEPARTMENT OF HEALTH SERVICES EnvironmentahMealth alth Personal He - 'r O BOX��1 6 SHELT� ON '9�8584 LOCAL (36%427-9670 ,m a x BELFAIR (36d)275-4467 °^ � Application for .Determination of Adequacy FAx (3so)'427-77ss C Instruct►ons i 1. Complete Part 1 No detevniaahon can lie tnad u A_w art 1 1s fullyy co•?°rm'iilefed 2. Completelonnly the,poruon of Part 2 applying for th type oC water syswtreni uu e'd Submitom leted a hcation, with attachments to,the health de arhnenttfor�reylew ;�AR*T 1: Applicant/Parcel Identification AZ , / Z at Name of Applicant V r_Y �rt?� I C�aJ`B tV Date f a Mailing Address Telephone Assessor's Parcel Number Type of Water System (Check On):; Reason for Appkcatron1(Check One): 'Public/community water system(2 or, 'Buildmg'pemut ` more connections) 1Vew o . Private Two-party ❑ . Replaceffixisting-Structure. a�. . ,t. o` ,Individual well (one connection) ❑ Latid us_applibation;if so... ❑= Well ❑ Division of land ❑, Spring/surface water #.of parcels? `a ❑ Other(explain) SPH,2f ❑ �Bounndary line adjustment ysy � f ❑. 'O,SI(explain) , PART 2 - Water System Infor mation ' r. Complete•the section appropriate for the type of water system,being evaluated;for,adequacyi r� tc - Y. 1 r rablic Water S stem' 4 Name of Water System i ,' � != �' i Wit"Facility Inventory (WFI')Ntt�tnber: C�5 _�C— t ad El't , The water purveyor has filed a Aeft rtgranting blanket hookups to this water system. °, 1•r;. y r 1 am the n�an�ger of this water system=fThe water system h been approved for r t-s ise icess'There are ,; = r presently .h connections to use This will be thecoruiec n swater�system is able and willing to pr"ovtTe water to thrs (ttRese)'connec[ions wi out exceedtiig the lumts of the water system or any 1; limits set by state and local-regu anon: �' Signature of Water System Manag� I F Date HAWELLUVATERAD3.WP.DOC Update:March 22,1999