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HomeMy WebLinkAboutBLD2018-00370 - BLD Water Adequacy - 5/18/2018 REC�►1/E dENTAL p EALTi b p�N 8 i . Always working for a safer , healthier Mason County 613r w %er Street 415 N 6`h Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ext 400 FAX (360)427-7787 Application for Determination of Adequacy 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 Name on Applicant: C Date: F Mailing Address: 'rf, iP tL C. ` hone:: Parcel Number.: I Z 12 19 Type of Water System Reason for Application • j Public/Community Water System (2 or more Building permit ccnnections) ❑ Division of land: =i Individua vvater source (one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) J Replacement(please indicate name of water If you have more than one residence connected system below if applicable—no signature to this well, check the Public/Community Water required) System box. 1?t✓Pt-AUrJC1 +_X(STtea A11-ANIr y ° Part 2: Water System Information v4 Ll l.(-,c K11�3+3- Ne Complete the section appropriate for the type of water system being evaluated: Public Water System Name of Water System: 12A l o i '. V t t;,W ICJ R Ttzi .. 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 (i.e.: 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 .1^1-H Forms,Drinking Water Revised 12/1/15 Page 1 of 2 This form may be scanned and available for public view on the Mason County Web site. Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) gpm gpd. The well driller often performs 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 recovery data, must be performed by a licensed contractor. ❑ Satisfactory bacteriological test(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) pi,, ❑ 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 Departmental Use Only: Do not write below this line. Part 3: Mason County Public Health Evaluation ❑ Satisfactory Determination: Applicant's water supply does appear 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 in 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 .J A`I I Forms,Drinking Water Revised 12/1/15 Page 2 of 2 This form may be scanned and available for public view on the Mason County Web site.