HomeMy WebLinkAboutWAT Application - 6/29/2017 MASON COUNTY
COMMUNITY SERVICES
a ddi yHl m%EmirmmentalHealth Community Health
415 N 6-Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 O Betlair(360)275-4467 ext 400 O Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Determination of Adequacy
Instructions
t. Complete Part 1. 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 on
Applicant: 5TA46.10f k4a,r A..! Date:
Mailing Address: s49f NF///�Xsoav �2d Phone" 3bo - yW0 - s-272
Parcel Number:: �'' '""� ,eM
z3 Y/ - jei 7"
Type of Water System Reason for Application
�C PubliGCommunity Water System(2 or more ° Building permit
connections) 0 Division of land:
Individual water source(one connection), 0 of Parcels? SPL
• Well n Boundary line adjustment
• Spring/surface water
u Other(explain) Pr, Other(explain) r3r_e p zPcac4r*�gTrr
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 Public7Communify 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: 'AEZ 4cA a Utz
Water Facility Inventory (WFI)Number. 12 - -aO
(write"none"for two-party)
-or,am 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.
`� I am the manager of this system.This connection will be to upgrade or change the use of an existing
/ \connection on this system(i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willin to proA�alll
these)connection(s)without exceeding the
limits of the water system or any its s begulation.
Signature of Water System Mana r Date A*
43
This form may be scanned and available for public view on the Mason County Web site.
Individual Water Well
D Water well report(attached to application). Depth ft.
Well capacity Test(attached to application) gpm gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results
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 applicant or if the 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(attach to application).
Individual SpringlSurface Water
WDOE permit(attach to application)
D Method of disinfection
D 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
Departmental Use Only: Do not write below this line.
Part 3: Mason County Public Health Evaluation
• Satisfactory Determination:
Applicant's water supply does appear adequate to meet the needs of its intended use. This determination
tices not address adequacy of the distribution system,guarantee an adequate supply of water indefinitely
in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Remmmended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination
of Adequacy for Building Pennds are satisfied. Additional Growth Management requirements may apply.
Chapter 36.70A RCW.
• Unsatisfactory Determination:
Applicant's water supply tices not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signature: Date
L\EH FomaA Drhnung Wafer
Pege7 of
This form may be scanned and available for public view on the Mason County Web site.