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Home My WebLink AboutBLD Water Adequacy - 10/12/2001 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 5••,:.....a,x.i:,.....,, ,... a ;';i££i ................ !!:£i :ii ££; ;;; x ......is x.x....x.., i i%i%ii£ ilx tl.i.iaia: .NAME OF AP-PLICA14T ALB. P 1 (&Aky, 6A9 A1'j=j0/kQ '� DATE L)EC- I C1 'S MAILING ADDRESS I �( ?,& JA-btiom y W TELEPHONE (20G, ) 4(13 'SS µ2- V"t�nn _ u)A g8o7D r _ �zo�) 03-5542 City Bt�ta Sly p� ASSESSOR'S PARCEL NUMBER 22304 -7-I7 �O 10/0 2 3 N 72 Vj -F E/ S C�¢ fW� SUBDIVISION (If Applicable) �F-C(GKS$,� LAKE I C) T., LOT 13 O �b-,ROCTI PAT AoD,ToQS f(Lr-,'k 4i� 22.2� TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) 12�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 Other PART 2—A: PUBLIC WATER SYSTEM €€€......€€€€€ " ........... . ............. €€ 3333€ w ::aa......:;:ri! .e .....i......:u...!£ ... NAME OF WATER SYSTEM F—Q€(-K5DN LAKE A6eOL. n.lxi.5,i.n,.l.e.e.!,rx!aIx W•u!FI:. I.D6i €7!€!2 i.€-i€€(/€V€€J€i€ I The water purveyor for this system has previously filed a certificate of water adequacy with the health district. I an manager of the s6vvv referenced water system. The water system has DOB approval for 1 L 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. SIGNATURE OF SYSTEM MANAGER Q, DATE ` (/ W-7 PART 2-B: INDIVIDUAL WELL 11lSli€Slid€€€€i€€€€333111€ll li li€1€i€€€€€€3€33l111lSS3€i€i!l ll 111 111 llltll llll li113331!l1111111l13 i1l11111111€€1ilIIIII Il111iSSUii!l1111liili l€tI!!Si€€ii€€€11 3 11111 3 3 1i i1i WELL DEPTH Ft WELL CAPACITY Gallons/Minute Gallons/Day El 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 well capacity test moat be performed by a licensed contractor. Baler or pump tests are acceptable, provided stabilization of draw-dawn has been measured and recorded. El Satisfactory total coliform test is attached to this application. PART 2-C: INDIVIDUAL. SPRING OR SURFACE WATER - . -- - x+.-a a.+. ..+a a...a.a+ a+ +.+.x".+.- ...-. a1.133!llll+i.++.aaa+i�a all FS31-lii"i+la+{+a.3.+!!}i +ii- +.£ _li 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) €€€.....€€..... 3€,iE El li li l l€l i-s 11 i€'•.i 3€......... 1.i 3€!€il€i£!!:i€€338€€':€3€!sli ii is33333tElli lii:iil'iis3€€lst!}3ii333€€333€3€€li31'::111i3€83€311lE:11€31€€€!€lil:'€€€!!!i3 ❑ 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 resource regu- lations. 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 Rev!'•,' ng/01/92