HomeMy WebLinkAboutWAT2023-00263 - WAT Application - 9/25/2023 411111.1111.1
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MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health - Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467
FAX(360)427-7798
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 of Applicant i/.f-`1[/113 /Ali Lc_ L Date If'i/aC' 3
1 ''53
Mailing Address ),?1--.l�/-Si%��/�.' _ , �/L Telephone a
riA
Assessor's Parcel Number. i°'./ .0)ikellr �F, `"
Type of Water System(Check One): Reason for Application Check One):
Public,/Community Water System(2 ormon ;IC Building permit w �3- on 6
conneWone)" a Land use applica
o Individual water source(one connection), O Division of land:
if so..
Well #of Parcels? SPH -
Spring/surface water
CI Other(explain) 13 Boundary line adjustment
"If you have more than one residence ❑ Other(explain)
connected to this well,check the Public 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 414D -'f,{]/1 F/h�
Water FaciliV Inventory (WF1)Number. d 5 7<<3 3
(write"none for two party) Inactive to Active Connection
The water purveyor has filed a letter granting blanket hookups to this water system.
I am the manager of this water system. The water system has been approved for services.
There are presentlyconnections in use. This will be the connection. this water
system is able and willingto provide 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 t+`�,,a,� < t<<Lk:A-4 Date 09/25/2023
Update:December 2005
rr.
Individual Water Well
Water well report(attach to application)Depth ft. //!1
Well capacity test(attach 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 wafer 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 tottach 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 no(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 Rt i\-Q-K49 " / t DATE tI ii 1-6--—3
Update:December 2005