HomeMy WebLinkAboutBLD Water Adequacy - 1/16/1997 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES _
,environmental Health
Water Quality Persona Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
FREE 1-800-562-5628
A implication for Determination of Adequacy TOLL FAX(3b0)427-7798
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Instructions
Cxtplete P 1 Nv cleterriuctaiioli can be made untzl Fart 1 zs �tly h .npifed. ,�
Z Corrrplete cznly the ptsrkxon of Park applying to the type of water system akil�zed
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urmt cbtriPletet ]catiau,will attaclnxez<ts tb;tlie;lxealtltent,l'p view
PART 1: Applicant/Parcel Identification
Date
Name of Applicant
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Mailing Address -P0 Telephone ( 360) 3 Z-Z 3 4-4 R�I�-'crr'r 1J'h q�5Z 8
Assessor's Parcel Number s 31D 7 7 0 0 ��
Type of Water System Check One): Reason or Application Check One):
❑ 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 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. 79s water system is able and
willing to pro water to this(these),connections without exce-eTmg the limits of the water system or any limits
set by state and local regulation.
Signature of Water System Manager Date
K•IWDATAWRCHrMWATEMIWP Update:October20,1995
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Individual Water Well
Water well report(attach to application) Depth —! 3 ft.
Well capacity test(attach to application) /0 gpm 14,46V gpd
Well ca acity tests are often performed by the well driller at the time the well is constructed. Test
resultsyrom 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 draw-down and recovery data, must
be performed by a licensed contractor.
Satisfactory bacteriological test(attach to application)
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Individual S rin /Sur ace Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
o 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 tbis line.
.. .:
❑ ::>: ::SSA I�p V ���X DETE�A . 0 App�a cants;watex suPl?�Y appears adecluat�to
apt thh nee els.0 its intepd d use:
zs delermition e r address adequacy> f the di,�trTbzttvn stem,.:guarantee
.........;adequate srly of water zndefi�ritely into theittare, ruartitee cm0liance
with all ap6lzcable Nd water resource regrzlataoys
❑ UrI ATISF TO t DETE III Af ON Applicant's water supply does not appear
adequate to meet the:needs o..xis.intended use fox the following reason (s)
IEWR'S .. 'f ]E DATE'
H:IWDATAIARCHIMWATERAD3.WP Update:October 20,1995