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MASON COUNTY
DEPARTMENT OF HEALTH 5ERVICES
Environmental Health Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467
Application for Determination of Adequacy FAX(360)427-7798
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
�1 � 1 2008
Name of Applicant DQQate .emu - �
Mailing Address r r- a elephone 00
Assessor's Parcel Number /o2R / ¢moots-Y_3 .753 `905-73 Y
Type of Water System Check One): Reason for Application Check One):
Public/Community Water System (2 or more Building permit
connecuona)' ❑ Land use application, if so..
❑ Individual water source(one connecuon), ❑ Division of land:
if so..
Well It of Parcels?�_ SPL -
Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
•'If you have more than one residence ❑ Replacement(please indicate name ofwater system
connected to this well,check the Public box. below if applicable-no signature required)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System
Water Facility Inventory(WFI) Number:
(write "none"for two party)
I am the manager oft s water system.The water system has been ap roved for services.
There are presently�connection(s)in use. This will be the irconnechon.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an
existing connection on this system(ie:recreational to full time). Please indicate on the following
I
ine the nature of this change:
This water 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.
Signature of Water System Manager Date
Upole.Apr112006
is -FAx:# 310
Individual Water Well
Water well report(attach to application) Depth ft.
Well capacity test(attach to application) gpm apd
e well driliero en pe orms wall capacilytests at the time thewe /s COnStrUCted Results
from these tests are noted on the water well mport. Results from these tests will be
accepted. lfthe waterwell report cannot be locatedbythe applicant orifthe waterwell report
does not have a capacity test,a well capacdy test which provides stabilization ofdmw-down
and recoverydata must be rformed by a licensed contractor.
Satisfactory bacteriological test(attain to application)
Individual SpringirSurface 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 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 notaddress adequacyof 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 (a):
REVIEWER'S SIGNATURE DATE
Update.April 20L