HomeMy WebLinkAboutWAT Application - 3/12/2007 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467
Application for Determination of Adequacy FAX(360)427-7798
Instructions
1. 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 of Applicant ML Design Group - Richard T gie Date March 12 2007
1550 140th Ave Ste. loo
Mailing Address Bellevue WA 98005-4516 Telephone(425) 746-4677
Assessors Parcel Number 123294190190 / 123294190230 (currently two parcels, being combined)
Type of Water System Check One): Reason for Application Check One):
® Public/Community Water System (2 or more ® Building permit
connections)' o Land use application, if so..
❑ Individual water source(one connection), ❑ Division of land:
IT so..
Well #of Paroels? 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 aelfair water District 41
Water Facility Inventory (WFI) Number: d 5350
(write"none"for two parry)
in I am the manager of this water system.The water system has been approved forte services.
There are presently S 0.1 onnection(s)in use. This will be the.5,23 onnection.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an
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 s3— OS—r�7
U,x aw Apd12006
Individual Water Well
Water well report(attach to application)Depth ft.
Well Capacity test(attach to applicaton) gpm gpd
e"it anilerotten pe rms we capac es s a e time a we 1s constructed.Results
from these tests ere noted on the water well report. Results from these tests will be
accepted. If the water well report cannot be located by the applicant orif the waterwell report
does not have a capacity test,a Well capacity test, which provides stabilization ofdraw-down
and recoverydata must be dormed by a licensed contractor.
Satisfactory bacteriological test(attach to apoicauan)
Individual SpringlSurface 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 not address adequacy of the distribution system,guarantee
an adequate supply of water inderinitely 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 (s):
REVIEWER'S SIGNATURE DATE
Up&w Apn12W6