HomeMy WebLinkAboutWAT Application - 7/7/2003 MA50NCOUNTY
DEPARTMENT OF HEALTH SERVICES
Personal Health
Emiranmen(al Health
PO BOX 1666 SHELTON,WA 98594
LOCAL(360)427-9670
BELFAIR(360)2754467&4468
Application for Determination of Adequacy
Instructions
t Complete Pao 1. No determination can be made until Pan I is full comvlcted
2. Complete only the portion of part 2 applying to the type of water system utilized.
�Submit completed apphcati�n with attachments to the health department for review.
PART 1: Applicant/Parcel Identification
Name of Applicant�*P&A 4` h"'( :g,v 44ePAWV614, Date 2 7//a.7
Mailing Address -'T'64 J'. ryas W1 ex Ro Telephone ;10 -l7/-/-fT7
•a
Assessor's Parcel Number ;a I lr rm 6601
Type of Water System Check One : Reason forA licatlon Check One
w Public/Cot mitY Water System(2 or more W Building permit
connections) ❑ Land use application,if so..
❑ Individual water source(am annecden),if so.. ❑ Division of land
❑ Well ff of Parcels?
❑ Spring/surface water SPH9_-
❑ Other(explain) ❑ Boundary line adjustment
❑ Other(explaia)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water S stem
Name of Water System 4 *Xdt
Water Facility Inventory(WFI)Nrunber:
❑ The water purveyor has filed a letter granting blanket hookups m this water system.
❑ I am the manager of this water system. The water system has been approved for services. There are
presently connections m use. This will be the connection. is water system is able and
willing to pry water to this(these)wnnections wit out exceeding the limits of the water system or any
limits set by state and local regulation.
Signature of Water System Manager Date
H9WDATAURCfflMWAT6RAD3.WP Update:Mmch 22,IM
W - 7
Individual Water Well
Water well report(attach to application) Depth ft.
a Well capacity test(attach to application) gpm epd
Well cappacty tests are often performed by the well driller at the time the well a constructed Test
resullsJrom these test are noted on the water well report. Results from these tests will be accepted
tfthe water well report cannot be located by the applicam or ifthe water well report does not have
a capacity test, a well capacity test, which provides stabilization of draw-dawn and recovery data,
must be performed by a icensedcontractor.
O Satisfactory bacteriological test(aauh to application)
Individual SpringlSurface Water
o WDOE permit(attach to application)
o Method of disinfection
o I 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 aappplicant will reed to arrange an omrite inspection by
the health department prior to determination of aaequmy
Departmental use only. Do not write below this line.
PART3: Health Depa rtmentEvaluation (staff use only)
a - SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to
meet the needs of its intended use.
This determination does no address adequacy ofthe distribution system, guarantee
an adequate supply ofivater indefinitely into the future;or guarantee compliance
with all applicable WDOE)eater 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
HI WDATAURCHIVEIWATERAD3.WP UpdMc:March n,IM