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HomeMy WebLinkAboutBLD Water Adequacy - 8/30/2007 .., ,gip ...,� .,ass-wm; '.: .~•,� r�^., �",;� � _�;er�n�.^r�aa�,,n,, :ff�" '.-; �,„ ` a rppg. L1,63wttn T�q vi0 vnoav- V6x�, lXn, Nor, MA5QN COUNTY aEPARTMENT OF HEALTH, SERVICES 4�Fnvironmontal Health Pars4nal Health Po QX 1556$HELTQN,WA9555�} OCAL PQ0),427!B67Q, ` FAIR(350)275-467 liGation for ]determination of��.de�u��y FAX(��°? Instructions ±. Complete Part l..IjQ,'deternn atton,can be made until Fart 1 is full com t teed ' Compleke Drily the portion of Part 2 applying to the type of water system utilized 3, Submit completed a licatior►>with attachments to the health department for review, Applic anVParcelI entilic° ion e of�, lioant Nam pp. + Mailtn Addreas Telephone ' ssessor's Par��1 Number '����� �0� Reason or A lkattan f - J�I�of)%dater System (Cite �k One): PP Publc/oornity water system(2 or 1 �' �.mpre co trot Building permit , ,r ''Ina we'll(one connection a band use applicatton�i so o Well. a `Division of laid Sprin ,/surfac�water #of pa# s? p Other(explain) SPIf2 o boundary lute adjus440at ❑ Other(explaa�)" �.. � Y , i t w f " 4 r stem Information �?Vat+k Sy r ,�r system ben evaltitate�. or , etc the section a ro riate for the type of water Compl pP p 4� 41l ' v pr kV PctbAp lie �{'ater S stem laht Date System t aiIhty lrttor (WFi dumber; R � Q The water pprveyor has filed a letter granting blanket hookups to this water syslern, q l the manger of this water system, The water system has been approved fog �'leai` e presently connections to use, This will be the connection; raad 3 wtlling'to ptovr a water to this(these)connections wit out exceeding the linos of t)t ' � 1< 1 � limits Act b tpp pp�n/�t local regulation. ss j y St are of Water'System Manager, a � k2kPrt °d ,[k ry y53 { kfi ' t { r tt C1A�,t�Ra r tRt 3E On 2E4 t: I , s h3 t f t�' f ,,-,.wmf.,,-.r.e �a f,,rw-mr*rc� r^�^.� �,*,'.;R^-rr^nr.u,.�.•*n, �'�!.F,4... .-�'' °.�S.. .��=pr �r.....,. — ,:.fr Individual Water Well ❑ Water well report(attach to application) Depth Ir ft. Well capacity test(attach to application) 220 gpm god The well driller often performs well capacity tests at the time the well is constructed. Test results from 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 drawdown and recovery data, must be performed bV a licensed contractor. i Satisfactory bacteriological test(attach to application) j` 1 Individual Spring/Surface Water ❑ WDOE WR permit(attach to application) j - ❑ 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 (staff-use only 0 SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet the needs of its intended use. This determination does not address adequacy of the distribution system,guarantee an adequate supply o,f.water indefinitely into the`future, or guarantee compliance with all applicable WD©E water'resource regulations. IN, DETERMINATION: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s): REVIEWER'S SIGNATURE DATE Update:March 22,1999