HomeMy WebLinkAboutWAT Application - 12/2/1992 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
IIItUllllllllllll111!lliitllltllllitlllllllllilllllllllltiilitlllililllllllllliillillllilllllitlliltllllllllllIlllllllllillilllfiltt11111111111111t11111111111t1Itllllllliilt
NAME OF APPLICANT L ,S V. V4 2YJ DATE 7)EC 2 / 9 9 Z--
MAILING ADDRESS ri/ E 2/ 2/ 0',0 9El-1=4/2 " y TELEPHONE (Zo% 1275^ 3Y70
esay ea�a� aiy
ASSESSOR'S PARCEL NUMBER / -2 ,3 / 7 C' I _
SUBDIVISION (if Applicable) -J?/Zql An-D LOT
TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One)
® Public/Community Water System ® Building Permit, Single Family Res
❑ Individual System, Drilled Well Building Permit, Commercial
El Individual System, Dug Well Building Permit, Replace/Remodel
El Individual System, Spring Land Use Application
Name
ElIndividual System, Surface Water Type
El Individual System, Other other
PART 2-A: PUBLIC WATER SYSTEM
Iiliillililtllililllllillttiliillllllllliillliiillilliillliitliitlilillllllllllllllllllllllliiliiltllllllllilitliliililillllilliiltiillllill111111l111111ltti1111111i1111l111
NAME OF WATER SYSTEM WFI ID
The water purveyor for this system has previously filed a certificate of voter sdegoacy with the hselth
district.
I em manager of the some referenced water system. The water system has DOH approval for _ ssrvice
connections, with connections presently in use. The applicant hse approval to coowet to this water
system. Service of rater to the applicant for domestic purposes is consistent with both the voter 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 attend the lines.
a p may,
SIGNATUAB OF SYSTEM MANAGES D71T8 ['2 C,
PART 2-B: INDIVIDUAL WELL
i!1li t!l ilil ll ll tli i illlIIIl113 t11i1 i11!lllll131i 1117t381ii1nlIIIIIII IIt1111111111311111l13l II311111111IIIIIIIIiIIllltlttl ilflll llltllli ll lli lllll 111 i iliil i li it illllll l li it
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
NOW: well capacity tests ars often performed by the well driller at the ties the wail 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 wall log cannot be located by the
Applicant, a wall capacity test suet be performed by a licensed contractor. ealar or pump
tests are accsptable, provided stabilization of draw-down has been msawired and recorded.
Satisfactory total coliform test is attached to this application.
PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER
Illii li it itiilii iil iililitll ll(i li ii lit i illiii iilifiitflii iiliii tlllllliillliiiilttl llllllllliili ill{Illflliillliltlt1111iiilifttlitllitlitlit1111ltfi111i t1f11ti i I111ii1 i fill
El
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 state,,,, 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)
nuuuluuuuoltunuuuuuuunlneullwluuwiiltiNlllnllillliauuuuuuuunuanuunuuunonunnuuuuunauunnuuuuuuuunnu
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 systes, guarantee an adequate supply
of water indefinitely into the future, or guarantee compliahn with all applicable WDOR water rewurce 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 INSPECT O DATE
R.4 - '9101/92