HomeMy WebLinkAboutBLD Water Adequacy - 4/20/1998 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
&nvi.onmentol H.1th w ter Quality Pe.eanal Health
PO BOX 1666 SHELTON, WA 98584
LOCAL (360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy TOLL FREE 1-800-562-5628
Application FAX(360)427-7798
Instructions
1. tk+mplete PaAlsNe dcterminati6ncan be maduafilPadlis •11v�ZetedS
2 Complete only the portion of Part 2 applying to the type of water'"car nfilized.
3, submit co kraal lioatiou,wtidt aaacbmemsto the health aromeatfarreview.
PART 1: Applicant/Parcel Identification
Name of Applicant 9 ri Ay') A C r) 01 j Date i4-�''Z a�g V
Mailing Address y � S �r i S 0 Ul �.N S E Telephone b 5 5 - �1 Z 7
1 nor 1 A rA 0���
Assessor's Parcel Number 9 2-7_D 7 - -7 S - 9Cl n 7-0
Type of Water S stem Check One : Reason for Application Check One
PubBdCommunity Water System(2«mwe Building permit
� among) ❑ Land use application,if so..
❑ Individual water source(one cm, 6-),if an. ❑ Division of land
❑ Well RofParoels7
❑ Spring/surface water SP119_
❑ 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 System
Name of Water System Tr e R K e a -
Water Facility Inventory (WFI)Number: _I / 9 I x
❑ The water purveyor has filed a letter granting blanket hookups to this water system/.
❑ I am the er of this water system. The water system been approved for {.p_—services. There are
presently connections muse. This will be the connection. -TG�� ivusss water system is able and
willing to pro a water to this(these)connections without ex mg the limits of the water system or any limits
set by state and local regulation.
Signature of Water System Manager Date
W-7 H:IWDATA9RC[MVWATFFAD3.WP Update:Uctober20,1995
Individual Water Well
❑ Water well report(attach to application) Depth ft.
❑ Well capacity test(attach to application) gpm gpd
Well c acity tests are often performed by the well driller at the time the well is constructed. Test
results)rom these tests are note an the water well report. Results firm these tests will be accepted.
Ifthe water well rep on cannot be located by the applicant or if the water well re ort does not have a
capacity test a wo capacity test,which provides stabilization ofdraw-down and recovery data, must
be performed by a licensed contractor.
❑ Satisfuctory,bacteriological test(a m eppho .)
Individual SpringlSurface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water source can provide at least 800 gallons per day and/or provides water
a[a rate of 2 gallons per minute based on the following observations.
AUTHOR OF STATENIENT 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 ofadequaey.
Departmental use only. Do not write below this line.
PART3i 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 Ayslem, guarantee
an adequate supply of water indefinitely into the future, or guarantee compliance
with all applicable WDOT 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
H.IWDATAWRCF11MWATFRAD3." Updete:Wober 20,1995