HomeMy WebLinkAboutWAT Application - 3/9/2005 MAR-14-2005 MON 07:29 All LAKE. CUSHMAN. MAINTENANCE 3608776713 P. 02
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MASON COUNTY
DEPARTMENT OF HEALTH SERVICES lb I
Environmental Health
Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy
Instructions
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PART 1: Applicant/Parcel Identification
Name of Applicant fievin 3-F8nl Date 3f q /05
Mailing Address 727 frlsod*e11,P'- nie N. Telephone 31in.S((a fc,'�(„q
Lcre-cttslannt Ilia ciliated
Assessor's Parcel Number 's 2,3.05.5 io 3oc,c) Div 12, Slock �i) Lo4 CoO
Type of Wafer System (Check One): Reason for Application (Check One):
/I,/ Public/Community Water System(z or more Building permit
connections) ❑ Land use application, if so..
❑ Individual water source(one connccton), if so.. ❑ Division of land
❑ Well
4 of Parcels?
❑ Spring/surface water SPH9 -
❑ Other(explain) ❑ 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 Lake (t�,tshman meiivi4 pi-Nance Corrirane�
Water Facility Inventory(WFI)Number. 035 act o
a The water purveyor has filed a letter gaming blanket hookups to this water system.
I am the maw of this water system. The water system has been approved for I�t(1 services. There ore
71 presently 1 i`9 n connections muse. Tins will bo the %- connection. iswater system is able and
willing to provide water to this these)connections without exceeding the limits of the water system or any
limits set by state and local regulation.
��_��� /J
Signature of Water System Manager QCL& yC.`YLQ pi) Date 3/g/0s
- 6xisf ing Conry,r+'on
H:IWDATAWRCHIVEIWATERADI Wr ❑pdatc:March 22,1999
W 7
MAR-14-2005 MON 07'30 AN LAKE, CUSHMAN. MAINTENANCE 3608776713 P. 03
Individual Water Well
or Water well report(attach to application) Depth ft.
❑ Well capacity test(attach to application) gpm rpd
Well capacity tests are often performed by the well driller at the time the well/t constructed Test
results m these tests are noted on the water well report. Results from these tarts will be accepted
If the water well report cannot be located by the applicant or tithe water well report does not have �.
a capacity test, a well capacity test, which provides stabilizanon of draw-down and recovery data,
must be performed by a(teemed contractor.
❑ Satisfactory bacteriological test(attach to application)
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Individual Spring/Surface Water
o WDOE permit(attach to application)
o Method of disinfection F
❑ I have reason to believe that this water source can provide at least 800 Rallons per day and/or provides
water at a rate of 2 gallons per minute based on the following observations.
ATM-TOROF STATEMENT DATE
RELATIONSHIP TO APPLICANT
In addition to providing the above statement, the applicant will need to arrange an on-sate inspection by
the health department prior to determination of adequacy.
Departmental use only. Do not write below this line.
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n.IWDAT4URCHNEIWATERuDJ.WP Update:March 12,1999
MAR-14-2005 MON 07129 AM LAKE. CUSHMAN, MAINTENANCE 3608776713 P. 01
FAX TRANSMITTAL
e� LAKE CUSHMAN MAINTENANCE COMPANY
01' Lessees Organization For The Lake Cushman Development
3740 N. Lake Cushman Road, Hoodsport, WA 98548-9711
(360) 877-5233 FAX: (360) 877-6713
TOLL FREE 1-888-777-6443
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DATE: 3/14/05 PAGES (Including Cover): 5
TO: Trisha Woolett COMPANY: Mason County Permit Center
FROM: Julie A. McGrady TITLE: Member Services Coordinator
RE: Lake Cushman Division 18, Block 3, Lot 60
Trisha,
Here is a Water Adequacy form for Kevin Stanley,Parcel #422055103060
Please feel free to contact me if you have any questions.
Thanks,
Julie A. McGrady
360-877-5233 x 12
memsrv@hctc.com
03/14/2005 08:36 FAX 360 427 7798 MASON CO PERMIT CTR Z001
s*wx::xxxi.a.. a:xxxa*x*xa
484 RX REPORT n*
**xx x:i:*x x x** : l:22 **
RECEPTION OK
TX/RA NI) 9962
CONNECTION TEL 3608776713
CONNECTION ID
ST. TIME 03/14 08:32
USAGE T 03'38
PGS. 5
RESULT OK