HomeMy WebLinkAboutBLD Water Adequacy - 11/9/2008 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES _
Environmental Health Personal Health
PO BOX 1666 SHELTON, WA 98584
LOCAL(360)427-9670
BELFAIR (360)275-4467
Application for Determination of Adequacy FAX(360)427-7798
Instructions
1'. Complete Part 1, No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part2 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
Name of Applicant WE.1taN.L Mmw-- Date I l-CMAIN �
Mailing Address 1b � w hawo'/ elephone 'ryrt��'%
Assessor's Parcel Number 123Z92 -90V2b
Type of Water System Check One): Reason for Application Check One):
❑ Public/Community Water System(2 or more ❑ Building permit
connections)** ❑ Land use application, if so..
Individual water source lone connection), ❑ Division of land:
if so..
K Well #of Parcels? SPL_
❑ Spring/surface water ❑ Boundary line ad'ustment
❑ Other(explain) Other(explain) u v
**If you have more than one residence ❑ Replacement(please indicate na of water system
connected to this well, check the Public box. below if applicable—no signature required)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System +'l0-yv%.' _ t �W Pam
Name of Water System Wes^ MSC— Tt,o�(y 41F1L_
Water Facility Inventory (WFI) Number:
(write"none"for two party)
❑ I am the manager of this water system. The water system has been approved for_services.
There are presently connection(s) in use. This will be the connection.
❑ I am the manager of this system. This connection will be to upgrade or change the use of an
existing connection on this system(ie: recreational to full time). Please indicate on the following
line the nature of this change:
This water system is able and willing to provide water to this(these)connection(s)without
exceeding the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date
I EHFORMSIWATERAD4.DOC Update:April 2006
Individual Water Well
❑ Water well report(attach to application) Depth ft.
❑ Well capacity test(attach to application) gpm gpd
e well driller often pertorms well capacity tests at the time the well is constructed. 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 draw-
down and recoverydata must be erformed b a licensed contractor.
❑ Satisfactory bacteriological test(attach to application)
Individual S rin /Surface Water
❑ WDOE permit (attach to application)
❑ Method of disinfection
❑ 1 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):
511— SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to,
meet the needs of its intended:use.
This:determination,doesnot address adequacy of the distribution system, guarantee
an adequate supplyafwaterindefinitelyintott)e future, orguarantee compliance with
all applicable WDOE water resource regulations.
0 UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear
adequate to meet the needs of its intended use for the following reason (s):
REVIEWER'S SIGNATU DATE D
�- - 1.,IEHF0RAiMWATERAD4.DOC Update:April 2006