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Home My WebLink AboutWAT2022-00181 - WAT Application - 6/23/2022 4i-- Aat1/021 " 0.01B 1 ENVIRONMENTAL HEALTH 01 1 x.o -ii ,.6" 011141 \ MASON COUNTY ir"or COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health 415 N 6th 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: NIA k-k- lt-k15111A-11-4, Date: 2, 2-022- . Mailing Address:Ljt3 t ,.....-. Vi.C1-14;1",U.a)—(../ Phone: . -7 '7 Parcel Number::2:2 MI i * OC)(.C) 1 Type of Water System Reason for Application V.—Public/Community Water System (2 or more "Pr. Building permit connections) 0 Division of land: 0 Individual water source(one connection), #of Parcels? SPL El Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) 0 Other(explain) El 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. Part 2: Water System Information Complete the section appropriate for the type of water system being evaluated: Public Water System Name of Water System: ' /Oh Water Facility Inventory(WFI)Number: 49('S 3 7 0 r (write"none"for two-party) kriam the manager of tt ter system.The water system has been a? ro ed fort:614a.services. There are presently IL. connection(s)in use.This will be the 0 connection. 0 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 reg lation. /61 ie Print Name of Water System Manager • Phone Signature of Water System Manager Date J:,E,H Forms\Drinking Water Revised 3/19/2021 Page 1 ot 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) ❑ 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 Departmental Use Only: Do not write below this line. Part 3: Mason County Public Health Evaluation Satisfactory Determination: Applicants 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. Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of Adequacy for Building Permits are satisfied, Additional Growth Management requirements may apply. Chapter 36.70A RCW. Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). C Reviewer's Signature: Date 1 Ii L y0?-')— J:\\E1d Forms\Drinking Water Revised 311912021 Page 2 of 2 This form may be scanned and available for public view on the Mason County Web site.