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HomeMy WebLinkAboutWAT Application - 12/23/2013 �l- �AgON CoritV C Public Health Always working for a safer healthier Mason County PO Box 1666,415 N Bw Street, Bldg 8,Shelton WA 98584. Shelton:(360)427-9670 ext 400 O Belfai360)24244687xt 400 ❖ Elma: (360)482-5269 aid 400 FAX (360) Application for Determination of Adequacy Instructions 1. Complete Part I. No determination can be matle until Part 1 is fully completed. 2. Complete only the portion of Part 2 applying to the type of water system u[i"ad. 3. Submit com feted application,with attachments to the health de amnent for review. Part 1: Applicant/ Parcel Identification // Name on Applicant LPs t9AWt,t Dale: Mailing Address: 9711 Cf is ._ CyF. VL. Phone:: 114 c Parcel Number: r110 ft"�y Type of Water System Reason for Application 112( Public/Community Water System (2 or more E/Building permit connections)' ❑ Division of land. ❑ Individual water source (one connection), #of Parcels?_ SPL ❑ well ❑ Boundary line adjustment �'• ❑ Spring/surface water Other(explain) 64g6+AVfV UN u �r ❑ Other(explain) ❑ 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 Public1community Water ��rr required) System box. �/7 C�ivDy /,.JprT� /j��ll3 e Part2: Water System Information r A ve //,vir - ,/g _ a . ( ¢ Complete the section appropriate for the type of water system being evaluated: /,/,41? Is ASS 6,TS V,Ey/ +4 _ Public Water System Name of Water System: Water Facility Inventory(WFI) Number (write-none"for two-party) ❑ 1 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. ❑ 1 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 slate and local regulation. Signature of Water System Manager Date Revised 7n013 Pea.142 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 ❑ 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 In addition to providing the above statement, the applicant will need to arrange an on-site inspection by Mason County Public Health prior to determining adequacy. Departmental Use Only: Do not write below this line. Part 3: Mason County Public Health Evaluation J 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 d 12f 2 v�ye x oa This form may be scanned and available for public view on the Mason County Web site.