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HomeMy WebLinkAboutWAT Application - 3/1/1992 MASO,' COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY Revisal 09/01/92 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 I I I i 11111118I N i t!i l i i 1!I H i i i i l l l l l l i l I!NAME OF APPLICANT _�11n111�!{INy I/�t�N aCI N NJ DI NA!Ti t E MAILING ADDRESS Z7 TELEPHONE I I H l l l l i t N t I I I O t�t N�/ASSESSOR'S PARCEL NUMBER 7�(/ / �!{ �� 0Dr) SUBDIVISION (If Applicable) LOT TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) F—I.Public/Community Water System © Building Permit, Single Family Has Individual System, Drilled Well Building Permit, Commercial Individual System, Dug Well 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 /IIIIIIIIIIIIIIUIIIIEIIIIIIIIUB I11111Iiil I IIIIIIIIIIIIIIIIIIIIIIII IIBIIIIBUBBBBBBBBBBBBBNIBIIUBBBDINIIII{IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIilililllllil,+hest^.:: NAME OF WATER SYSTEM WFI ID Tee wtat pmisyor for this Mtan has PxevloualY filed a certificate of voter 'ad oacy With the .health di.t ict. ElI an manager of the shove referenced Water sy . The wtar Mt has hoe approval for service cmmetiom, viN romworom, prnemtly in we. The applicant-hoe app to connect to thin rater .yet®. aer.,im of wtar to.the applicant for dmmtid Parpaeec fa omsistmt vlth both the wter eyetam pLo aed the voter right Pondt presently Ip effect. Water 11nae . ava33aEl. to the applicant-. propartY line, or the applicant pee mrde satisfactory arrangements to motmw the 11nes. ..:. 61mN1Va6 or an;re f NMLCIDI:. •x •..d`49'#\k}/M1ay. aAfB PART 2-11: INDIVIDUAL .WELL iil iilii liilii l it hl it I i I IIIII I I I i11111I I!!!SUI IlISIDl1!I II II IIIIiii IlI111III if t l ISlDIlillilll!I it 1I111I111111111I IItII I IIIII III II�In111111111iiliiiiliiiii Illiiil Illllli WELL DEPTH � q4 N Ft WELL CAPAOITY ' Gallons/Hinute Gallons/Day '-'�' Well log is attached to thisapplication `Y( Well capacity test results are attached to this application WJ188: Mall u,wcify taste ate often pmfoo ed by the wall driller at w t w well is con- atrYCtad. Teel ..ol. n, tlbm testa ai9 OOtad OC w wall lag. lbeelta I. tLeee testa Will be aco,p by w beeltb EapattAnt. If a Wall lap canoe[ ba lONw by w amlloant, a N11 mWiry test mat be parfaxfad by a lloen a mnttactot. siler or poop testa an axapteDla, p.o idod atabillmtion of do.. do,,, has been sea and tetnrded. Satisfactory total coliform test is attached to this application. . �IAJC�1 FIOUS� Gvi�[�j [�3c7ii�u�n/ � //��2 P S / V�G �PAfrfi' "tnDlf ttI h�i tf7l ( lu ' �I III ili II III 1 111 , 1 1111 , 1 1111, 111 f iil 1 111 I �1 1 ill IINI IIIIIII IIIIIIIIIIIIIIIIIiI 61 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 ou the following observations: AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT NOfN: In addl♦'^^ to prwldtng w abays ataf t, w applicant will aatl to mravpa m on-s14 lnspeetim by Cis W th d1striet prior to deNroimtlon of WpOaOp. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) II11111111IIIIIIIIUIIIIIIIIi1111liliiliilllllllllDlll!lIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIIIIIIIIIIIIIIIIIIItt11i11111111IIi111111ii1111111i1111i1ID1111111111111ii1111111111;,_ 'a'+,14ATISFACTORY 1DETERMINATIONni,Applicant'.e .eater:supply.,appearsyndequate,to, met4 ,,,,,, needs of its intended use. Note: Mis detevimtlm does not addrms ad ueoy of the distriinfion ayat®, g rmw ad adepu supply - of water I.W finitalY'loto w fotora, or gvarmw raryU. rm all aPPlfcable tiaON ester remut® rpu- latione. UNSATISFACTORY ➢ETERMINATION: Applicant's water supply - does not appear ade- quate to meet needs of its intended use for the following reason(s): I 4 ,LEALTHZNSPECTOR _ 1 ATE