HomeMy WebLinkAboutBLD Water Adequacy MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health Water Quality Personal Health
PO BOX 1666 SHELTON, WA 98584
LOCAL (360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy TOLL FREE 1-803600-562-5628
FAX ( ) 427-7798
Instructions
1.•:„ -Complete Part 1 ?No deterin nahtin-can be made until Part 1 is fully oomDleted.
2. Complete only the portion o€Pert 2 applying to the type of water system utilized
3. ۥ Submitcompleted applieatlon,crafh attachments to the health d"ptlmentfbrreview.
PART 1: Applicant/Parcel Identification
Name of Applicant CGVY\ u gate
Mailing Address 2--0'i,4 GJO ,,jJVelephone 13CC')L} h 7��
Assessor's Parcel Number
- Type of Water System(Check One):. Reason for Application Check One):
❑ Public/Community Water System(2 or more Building permit
connections) i ❑ Land use application,if so..
Individual water source(one connection),if so.. ❑ Division of land
Well #of Parcels?
❑ Spring/surface water SPH9_
❑ Other(explain) a 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.
❑ 1 am the manager of this water system. The water system has been approved for services. There are
presently connections muse. This will be the connection. water system is able and
willing to______connections
water to this(these)connections without exceeding the limits of the water system or any limits
set by state and local regulation.
Signature of Water System Manager Date
W-7 H:IWDATAURCHIVE\WATFJUD3.WP Update:October 20,1995
Individual Water Well
Water well report(attach to application) Depth 1 I$ ?&ft.
O Well capacity test(attach to application) gpm gpd
Well capacity tests are often performed by the well driller 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.
Ifthe water well report cannot be located by the applicant or ithe water well report does not have a
capacity test,a well capacitytest, which provides stabilization of draw-down and recovery data, must
be performed by a licensed contractor.
Satisfactory bacteriological test(attach to application)
Individual Spring/Surface 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.
PART 3: Health Department Evaluation (Staff Use Only)
❑ 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 of water indefinitely into the future, or guarantee compliance
with'all applicable WDOE water resource regulations.
❑ '' 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 SIGNATURE DATE
H:IWDATAL4RCHIVEIWATERAD3.WP Update:October 20, 1995