HomeMy WebLinkAboutWAT Application - 6/4/1992 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 186
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
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
DATE 6 - Y- %L
MAILING ADDRESS C c/62 Scwt. y /7< TELEPHONE (C f.) /79 Vi3/�i
/Jy.CCE C.1 //�C['�C. �. Z NLC [ilw?,A 0
ASSESSOR'S PARCEL NUMBER/PSG'SSTJ SCC"'1 I 2 c &t SOLD
3ns- - 0 a '
SUBDIVISION (If Applicable) LOT
TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One)
❑ Public/Community water System N Building Permit, Single Family Res
AIndividual System, Drilled Well — Building Permit, Commercial
Individual System, Dug Well U Building Permit, Replace/Remodel
❑ Individual System, Spring ❑ Land Use Application
Name
❑ Individual System, Surface Water Type
❑ Individual System, Other ❑ other
•
PART 2-A: PUBLIC WATER SYSTEM
NAME OF WATER SYSTEM WFI ID
The water purveyor for this system has previously filed a certificate of water adequacy with the health
❑ : ec manager of the above referenced water system. The water systcF has DOH approval for service
connections, wtth d on.-ec__ons presently in use. The ape:1cant has approval to connect to this water
system. Service of water to the appl scant for domestic purposes is consistent with both the water system
plea and the water right permit presently in effect. water lines are available to the applicant's property
line, or the applicant has made satisfactory arrangements to extend the lines.
STOP:COPE OF stray. :dXASEO DATE
PART 2-B: INDIVIDUAL WELL
, . ,!1•::u -:1- 'i ❑iilI IIII:I i . : , uI .:, S'LIl,ail u,. Ilr -i L--, ,,. i -1 .'i.!i!II�I
WELL DEPTH (� ) Ft WELL CAPACITY S 7.2 to
Gallons/Minute Gallons/Day
Well log is attached to this application
u Well capacity test results are attached to this application
NOTES: Well capacity teats are often performed by the well driller at the time the well is
constructed. Test results from these tests are noted on the well log. Results from these
tests will be accepted by the health department. If a welt log cannot be located by the
applicant, a well capacity test must be performed by a licensed Contractor. Baler or pump
tests are acceptable, provided stabilization of draw-down has been measured and recorded.
Satisfactory total coliform test is attached to this application.
PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER
u ; , a L , , ::• !
ii
WDOE permit is attached to this application
I have reason to believe the spring proposed as the water source will supply
adequate water its intended purpose. This belief is based on the following
observations:
AUTHOR OF STATEMENT DATE
RELATIONSHIP TO APPLICANT
Norr: In addition to providing the above statement, the applicant will need to arrange an on-site
inspection by the health district prior to determination of adequacy.
PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only)
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SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet
needs of its intended use.
Note: This determination does not address adequacy or the distribution system, guarantee an adequate supply
of water indefinitely into the future, or guarantee compliance with all applicable WDOE water resource regu-
lations.
ti
UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade-
quate to meet needs of its intended use for the following reason(s) :
HEALTH INSPECTOR DATE