HomeMy WebLinkAboutWAT Application • MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health - Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)2754467
Application for Determination of Adequacy FAX(360)427-7798
Instructions
1. Complete Part I. 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
-Name of Applicant tJ'.Chd1k5 -Za�nsa" Date
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- Mailing Address LI``ll E. Ht -y 302 &tfUr,vJ Telephone
— Assessor's Parcel Number I2229' 50-62007-
T e of Water System Check One): Reason for Application Check One):
❑ PubliclCommunity Water System(2 or more ❑ Building permit
commau.nsl" ❑ Land use application, if so..
❑ Individual water source(one connection), ❑ Division of land:
if so..
Well #of Parcels? SPL
Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
'•If you have more than one residence Replacement(please indicate name of water system
connected to this well,check the Public box. below if applicable—no signature required)
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 parry)
❑ 1 sent the manager of this water system.The water system has been approved for services.
There are presently connection(s)in use.This will be the connection.
❑ 1 am the manager of this system.This connection will be to upgade or change the use of m
existing connection on this system(ie:recreational to full time). Please indicate on the following
line the nature of this change:
This water system is able and willing to provide water to this(these)connection(s)without
exceeding the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date
Update:April 2W6
Individual Water Well
Water well report(attach to application)Depth ft.
Well capacity test(attach to application) gpm apd
e well driller often pe orms we capacl y es s a e time a we Is constructed.Results
from these tests are noted on the water well report. Results from these tests will be
accepted. Ifthe waterwell report cannot be locatedby the applicant orifthe waterwell mport
does not have a capacity test,a well capacity test, which provides stabilization of draw-down
and recove data must be performs b a licensed contractor.
Satisfactory bacteriological test(attach to application)
Individual S rin /Surface Water
WDOE permit (attach to application)
Method of disinfection
❑ 1 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 APPLICANT WILL NEED TO ARRANGE AN ON-SITE
INSPECTION BY THE HEALTH DEPARTMENT PRIOR TO DETERMINATION OF ADEQUACY.
Departmental use only. Do not write below this line.
PART 3: Health Department Evaluation (Staff Use Only)
SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to
meet the needs of its intended use.
This determination does notaddress adequacy of the d/sMbution system,guarantee
an adequate supply of water indefinitely into the future, or guarantee compliance
with all applicable WDOE water resource regulations.
UNSATISFACTORY DETERMINATION:Applicant's water supply does not appear
adequate to meet the needs of its intended use for the following reason (a):
REVIEWER'S SIGNATURE DATE
Updsm AW6I2006