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HomeMy WebLinkAboutBLD96-00919 - BLD Water Adequacy - 8/8/1996 MASON COUNTY 40 DEPARTMENT OP HEALTH SERVICES AUG 0 Environmental Health Water QuAh- AWN Parsonal Healtti bIT 66SHELtyry 98684 LOCAL(360)427-9670 " BELFAIR(360)275-4467&4468 TOLL FREE 1-800-562-5628 Application for Determination of Adequacy FAX(360)427-7798 Instructionsi11 � i, Complewltattl, ikdetor>nioafoutanbemadetmtill�arllrs $. Complete only fhe peaztionafPart 2 altPtB io the type of vrater a etemut 3, ` Sttbtnit eo lettd °'. li�tlon,w1Qt htnettts to th�lieaith d aiinteutforxeiriew.' PART 1: Applicant/Parcel Identification } Name of Applicant (N R s?AN Date Mailing Address �`��� C I ir,r) 9 01 Telephone 00 Liq 5 3 1 Assessor's Parcel Number S�Da6 -o� T e of Water--stem Check One): Reason for Application (Check One Public/Community Water System(2 ar mm Building permit connections) ❑ Land use application,if so.. ❑ Individual water source(oae oonneotim if so.. ❑ Division of land a ❑ well #of Parcels? ❑ Spring/surface water SPH9= adj ❑ Other(explain)�— ❑ Boundary line ustment ❑ 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 (WF Ntunber: ❑ The water purveyor has filed a letter granting blanket hookups to this water system. ved for services. There are con ❑ I son the manager of this water system. The wactlater system has been appm - connections m ster use. b v ut exec mg tthe henlmirts of the water s n. rystem or anyllimlts willing t�water to this(these) set by state and local regulation• Signature of Water System Manager Date H. DATAURCHIMWATERAWAP Update:October 20,I995 w-7 Individual Water Well ❑ Water well report(attach to application) Depth ft. ❑ Well capacity test(96ch to application) gpm gpd Well capacity tests are often performed by the well driller at the time the well is constructed. Test results m these tests are noted on the water well report. Results from these tests will be accepted. Ifthe water well rr ort 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) Individual SpringlSurface Water ❑ WDOE permit(attach to application) ❑ 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. PAST ; H+l�it�t�eparEme>at E+uaxua�it►u (S'tl�f,�'+LTs� llr�ly) © SATi3FACTORY DETERMINATION: Applicant's water an ply appears ad egaate to meet the needk of its intended use. This detemlilurxion d9a Ho address adequacy of the dislriJiutl4it system,guarantee' an adequate p 'flf w kr indefittftely iMo the f uttrre, or guarantee c4 mpliatrce spith aFi erppltt crbk WI)©E water resource reguladdns. UNS 4TISFAC FO1LY DETERMINATION: Applicant's water supply defies not appear, adequate to meet the needs of its lAt del use for the#allowing!reason(8): 1 lEWER`S SIt3NATLTRE DATE 6 X:1 DATAVRCH1MWA7ER,4D3.WP Update:October 20, 1995