HomeMy WebLinkAboutWAT Application - 3/20/2001 MA50N COUNTY
DEPARTMENT OF HEALTH SERVICES
E vlronmental Health Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy
Instructions
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PART 1: Applicant/Parcel Identification /
Name of Applicant S w Rq£OS+i Date '�r2t1r G
Mailing Address 946 0Aze41j,1,J A-. Telephone 3G0- y7 f—'72to
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Assessor's Parcel Number 7 a 2
Type of Wafer S stem Check One : Reason forA rlieatwn Ckeck One
Public/Community Water System(2 or m«e Building permit
connectiom) ❑ Land use application,if so..
❑ Individual water source(one amiwiae),if so.. ❑ Division of land
❑ Well pofparcels?
❑ Springtsurface water SPH9=
❑ Other(explain) ❑ Boundary line adjustment
❑ Other(explain)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water vstem
Name of Water System ¢. /3<0"`' - *^'"`' S r
Water Facility Inventory(WFI)Number: 6&'7-00 F
❑ The water purveyor has filed a letter granting blanket hookups to this water system.
❑ I am the manager of this water system. The water system has beenapproved for 3 6 services. Thete are
presently, Z� connections m use. This will be the 22r' connecton. u water system is able and
willing to provide water to this(these)connections wt ouit exceeding Ne limits of the water system or my
limits set by state and local reg atio
Signature of Water System Mana Date 3 ZG o
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,PC915 4 V14-715-R/5'S p-6✓w
H..-IMDAr.4WRCfflMWA7MDd.1rP Update:blank A1999
W - 7
Individual Water WeU t>
❑ Water well report(attach to application) Depth R
❑ Well capacity test(attach to application) gpm epd
Well ca acity tests are often performed by the well driller at the time the well is constructed Test
resulis from these tests are noted on the water well report Results from these tests will be accepted
If the 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-down and recovery data,
must be performed by a licensed contractor.
❑ Satisfactory bacteriological test(mach to application)
Individual rin u ace Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
o I have reasat 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 OP STATFAIENT 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 derermJrmtion of adequacy.
Departmental use only. Do not write below this line.
PARTS: Health Department Evaluation {Staff uee lJoty)
o .,SATISFACTORY DFI LRM1NA'I ION: Applicant's water supply appears adequate to �k
meet the needs of its intended use.
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an adequate supply of water indefinitely into the finu,e, or guarantee compliance
with all applicable IWOE water resource regtdatiorza. . .
❑ (.UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear
,adequate to meet the needs of its intended use for the following reason (s):.
REVIEWFR'S.SIGNATURF - - DATE
H IWDATAURCHIMWATERAD3 WP Upd :Much 22.EMl