HomeMy WebLinkAboutBLD Water Adequacy - 7/25/1995 SON 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
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NAME OF APPLICANT 0 l V t DATE '
MAILING ADDRESS Li VV_ W TELEPHONE ( )
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ASSESSOR'S PARCEL NUMBER 1.�3a ► - ay -� v��\�
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 Building Permit, Replace/Remodel
IJ Individual System, Spring El Land Use Application
❑ Name
Individual System, Surface Water '
El Individual System, Other her
PART 2-A: PUBLIC WATER SYS �II III 1� �_� �� IIIIIIIIIIIII
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NAME OF WATER BY WFIID
The water purveyor for system has fi a u of water health
district.
�.I as manager of the above referenced water systss. water system has DOB approval for_ serv, e
connections, with _ conneati4mo presently In use. applicant has approval to connect to this water
system. Service of water to the off l a r domestic s is consistent with both the water apstem
plan and the water right permit presently is effe Hater lines available to. the applicant's property
line, or the applicant has made satisfactory arrangements nd lines.
SIGNATURE OF SYSTEM (MANAGER DATE
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PART 2-11: INDIVIDUAL WELL I
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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
w=s: well capacity tests ate often parforsed by the wil driller at the time the well is con-
structed. Test results fron these tests ate noted on the well log. Results fro thaes
tests will be accepted by the health apartment. if a wll log cannot be located by the
applicant, a Well capacity test sust be performed by a licensed ecntractor. B&IOX w pump
teats are acceptable, provided stabilization of dra down has been measured and recorded.
Satisfactory total coliform test is attached to this application.
PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER
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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
ROTE: 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)
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SATISFACTORY DETERMINATIONi Applicant's water supply appears adequate to meet
needs of its intended use.
Rots: This deteralnstios does not address adequacy of the distribution !yeses, guarestes an adequate supply
of ester Indefinitely into the future, cz guarantee cospliano with all applicable VDW vatez sssoorca rsga-
latios.
El UNSATISFACTORY DETERMINATIONS 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'' "' nq/01/92