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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 I 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 xe.ixam^u This form may be scanned and available for public view on the Mason County Web site. Scented with CemScanner 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 M013 hp 2 oft This form may be scanned and available for public view on the Mason County Web site. Scanned with CamScannee 1 a is WATER WELL REPORT Y ., :D^1.r'a qoddwAl•..rr-ea.v.YerF-.....a"r.n-a.m.r CURRENT .l.e l Natice of Intent No. N onstructloolDecommissloo("z"in circle) 1a ® (.0651NCllon Unique Ecology Well ID Tag No.�dL�A7 ;A ��i--o'IID GR/GlNAL fNSlALL17TON WNtt Rlghl Permit No.e o _ w 1 Nut=D INeN Number brE= Propvly Owntt Neme NICK NIfN noeoaaot G m O b ❑ wwiHnd C ❑NWw ❑bamnm ❑Tra WM ❑W Well SD Address 110 ELDMAR HOLLGW O 0 T oRK: o..w'..mbt.fwdl lam.as City BNELTCounty MASONCoon8N4tl 0 O N..—m ❑arme®s u.dd:❑ DI O ❑ wsw O o� ❑aN. ® RBomd O Nma L9ce0on 7Byl/4-1/4 fpyl/1 Sec jl Twn jl Rj R DImmaoYA IX orwra§ind dnawjRl [wN D E a .rate wwNR p CON ULTIONDCTADS Lat/l oeg Cube ®Wm a. q tee lLb llln (ALr SBII VI Deg _ Min_Sec s..bua: ❑ Im mv.nr_• Dom a.R_a.b JL REQUDLED) Long Deg_ Min_ Sec _ QI ❑ Tb.WN _• puy F�m_6b _6 CUNYInLr.T10NOR DCCYlMML4fIDN PROCCDOR6 FvsYla'Dmasyafw,.h.m,.v NmwwiJrd.mam..N W ld W P.hntls Yn W of0[mwultlbsh.vww.mrmW.LwalmlmemnvrbeNn..ro Tryedpvfvbv mad_ dblvuioe. 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