HomeMy WebLinkAboutWAT Application - 4/2/2007 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health - Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
Application for Determination of Adequacy BELFFAX(�;4Z6�98
PP 9 Y
Instructions
1, No Daft ba ;
o�N'll?YpetlNh'..,� a12. ..
PART 1: Applicant/Parcel Identification -
Name of Applicantl/// l�n �'�jlye(,rZS `/,e Date 7- 7
Mailing Address VIS flan 6A AQ rrp(at Telephone �3D - 3 77 -5 S /3
Assessor's Parcel Number 75- 9oa/3
Type of Water System Check One): Reason for A lication Check One);
❑ PubliclCommunity Water System(2 or awn 4 Building permit
eonnaaaona)- ❑ Land use application,if so..
Individual water source(one connection), ❑ Division of lard:
If so..
Well #of Parcels? SPL
Spdng/sudace water ❑ Boundary line adjustment ---
o Other(explain)_ ❑ Other(explain)_
If you have more than one residence o Replacement(please indicate name of water system
connected to this well, check the Public box below g 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 party)
❑ I am the manager of this water system.The water system has been approved for services.
There are presently connecbon(s)in use.This will be the_connection.
❑ I am the manager of this system.This connection will be to upgade or change the use of an
existing connection on this system(ie:recreational to full timc).Please indicate on the following
line the nature ofthis change:
This water system is able and willing to provide water to this(these)connextion(s)without
exceeding the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date
updare AM]2006
Individual Water Well
Water well report(attach to application)Depth a318 ft.
Well capacityiesl(atlachtoapplication) 120 gpm - _gpd
T17o wall awlerafteriperforms wellcapactryes 17B&time the"Nis constructed. esu
from these tests are noted on the water well report. Resuhs from these tests will be
accepted. ifthewaterwellre r1cannotbelocatetlbY Neapplicantorilthewaterwell report
does not have a capacity test,a well capacitytest whMh povides stabilization ofdmwzwown
and recoverydata must be rformedb alicensedcontractor.
Saasfactoly bacteriological test(meth 0 sppll m)
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 ggallons ppeerr da and/or
provides water at a rate of 2 gallons per minute based on the following observaaMS. y
AUTHOR OF STATEMENT_ __ DATE
REt noNsNlp To PPPL1GnT
IN ADDITION To WOVMING THE ABOVE STATENUrr,THE IGANr WILL NEED To A NGE AN ONSRE
INSPECTION BY THE HE TH DEPARTMENT PRIOR To DETERm1UT10N OF ADEQUACY.
Departmental use only. Do not write below this line.
PART 3: Health Osparhment Evaluation (Staff Use Only)
SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to
meet the needs of Its intended use.
This determinatlon ago nof.address adequacyofMe distribution 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 Is):
REVIEWER'S SIGNATURE __ DATE _
Up",Ap^2"
WATER WEU REPORT / {;
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