HomeMy WebLinkAboutBLD Sewer Adequacy - 1/24/2024 „ ,SON COtiVsy
Public Health
Nwayr W."Fora heslWuww0ionty
PO Box 1666,415 N an Street Bide 8,Sheiton WA 98584.
She11on:(360)427-W70eM400 4 Belfalr:(360)276-4467axi400 O Elma(360)482-5269e4400
FAX (360)427-T787
Application for Determination of Adequacy
Instructions
1. Complete Par”
. No determination can be made until Part 1 is inlN oomaleted.
2. Cwnplete only the portion of Pan 2 applying to the type of water system utilized.3. Submit com latedapplication,with attachments to the heaitli de aMrent for review.
Part 1: Applicant/Parcel Identification
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Name on Applicant ti\C k.- W N I V Date. 1'ILA'7u
Mailing Address: (lo E. Ard-mr\N PZ. C-iYYl��tm^e:: �'J3 - 43\'g2I�IParcel Number: )y� 47 bn0
Type of Water System Reason for 4Application
❑ PubliclCommunity Water System(2 or more ❑ Building permit I.OW) 2024- �b�
connections)" ❑ Division of land:
Individual star source connection), #of Parcels? $PL
well ❑ Boundary line adjustment
❑ Spdnglsurface water ❑ Other(explain)
❑ 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 PubtinCommunity,Water required)
System 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:
Water Facility Inventory(WFI)Number.
(write-none-for two-pady)
❑ I am the manager of this water system.The water system has been approved for_servi]Mtum
There are presently connections)In use.This will be the connection.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an
connection on this system(Le.:recreational to full time).Please Indicate on the following line of this change:
This water system is able and willing to provide water to this(these)conneclion(s)without ex
the Omits of the water system or any limits set by slate and oral regulation.
Signature of Water System Manager Date
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This form may be scanned and available for public view on the Mason County Web site.
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Individual Water Well
3/Water well report(attached to application). Depth,�l�ft
k�, �y�
V Well capacity Test(attached to application) "N apm�td,Lyptl. )
The wall driller often performs well capacity testa at the time the well is constructed. Results
from these tests are noted on the water well mpon 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 awell capacity teat,which provides stabilization of draw-down and
recovery data,must be performed by a licensed contractor.
❑ Satisfactory bacteriological test(altach to application).
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water sources can provide at least 800 gallons per day,andlor
provides water at a rate of 2 galons 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 Evaluatio:dinb
❑ Satisfactory Determination:
Applicants water supply does appear adequate toeeds of Its intended use.
This determination does not address adequacy of bon system,guarantee
an adequate supply of water Indefinitely In the futuantee compliance with allapplicable WDOE water resource regulations.
❑ Unsatisfactory Determination:Applicants water supply does not appear adequathe needs of its intendeduse for the following reason(s)Reviewers Signature: e
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This form may be scanned and available for public view on the Mason County Web site.
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Thurston County Environmental Health
2000 Lakeridge Dr.5W •Olympia,WA 98502
360 867-2631
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