The URL can be used to link to this page

Home My WebLink AboutBLD Water Adequacy - 6/6/1994 l /M UA UUUNIy IJ Yr 11NMINI Ur nl: 111 JSSrt a 1tro POST OFFICE BOX 166,, SHELTON, WA 98584 (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY Revised 09/01/92 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 1:!HiH{Ilii lill!!!!Ilt!E:::!iiiRN Hii!!!ie!!{;!::ii il{II!!iN{:itn!it!::11i!B:{Ifti ll:!11!i!!i!aii ilf dill Nilil ll!if:E!:i iii lii lli liU!I://N!::a�45� DATE L /6 NAME OF APPLICANT L 4E R✓ a 4 L .�—�-- MAILING ADDRESS 4320 / 94 cT Sul S yY B- TELEPHONE (20f Wee et-�- Cz� ASSESSOR'S PARCEL NUMBER 3 2 a 0 3 a2S7 000[)D SUBDIVISION (If Applicable) LOT TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) Public/Community Water System Building Permit, Single Family Rea Individual System, Drilled Well Building Permit, commercial ❑ Individual System, Dug Well Building Permit, Replace/Remodel El Individual System, Spring Land Use Application Name ❑ Individual System, Surface Water Type ❑ Individual System, Other Other PART 2-A: PUBLIC WATER SYSTEM Bn nuf nuauu ununnw a uunnuunmiunu nrtmunm uuuuuunNltniNNlNittlNiB;lillilil ittiilf itit INnt NN n uu tlt!uutunuuml IBI uB NAME OF WATER SYSTEM WFI ID Me water purveyor for this syatem has prwlwaly f11ed a certificate of water aEe9u+cY sit, tea health district. ❑ _ service x av manager of the aLove referent] water system. The eater aystaa has DOa approval for connections, with oomectlons presently in use. The applicant has appxovel On connect W this water eye.. Service of water to the epplinshe for daaetic purpoeee in conalatent v1i3h both the —ter eY°t® plan and the water right permit pressurly is effeet. avatar lines are availalle to the apPlicant's property line, or the applicant has made satisfactory arrangazents W extend the lines. DATE SICNAI,IRE OF SYSTEM MANAGER PART 2-11: INDIVIDUAL WELL !!!t1111111l111Iii I i i it iii li it ii i i I i i IiiIi111111D1 iD;il!!II I II II II IIIIII I II IIIIII lii ll l ll ll}III I}lii I II IIIii I Iii l I i❑:I:E;I}IIIII}1n11!It}}I11lil l l III II}I iii I III Iliiili!I} WELL DEPTH Ft WELL CAPACITY Gallons/Minute Gallons/Day Well log is attached to this application Well capacity test results are attached to this application NOfE9: well Capacity teat- are often performed by the well Griller at the time the well is con- strntted. Teat reauats from these testa are retell on the well lop. Neamits from these teats will be accepted by the health department. If a well leg Cannot be lecatad by the applicant, a well capacity test moat be performed by a licensed novtractac. Baler or pump teats are acceptable, provided etebillmation of draw-down has been meaeurad and recorded. Satisfactory total coliform test is attached to this application. PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER Hiiiiii n - _-_i iii i?H HII❑fiiiHlli1H11 i itlHiii it i 4ii:�:::::!cP.i!i:u u!iiH717I❑l r.m_:i„_:.,,, -• °""" -- -^"i"*I';;!IiH ill?tell liiil l li!!i WDOE permit is attached to this application I have reason to believe the spring proposed as the water source will supply adequate water its intended purpose. This belief is based on the following observations: AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT Nn'E: In addition to prwldial the above etateeast, the applicant will new; to aziange so -vita inapaetlm by the health di-trlet prier to detarmi:utim of adequacy. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) III11411111IIIIIIlIIIIIIIIIlIIIIIii IIIIIIIIIIIIIIIIIIiiil ll ll l ll lllllllll IIIIII IIIIIIIIIIIIIII IIHIH iHlll!IIIIIIIIil1111!it IIIIIIiill N I II ii II IIIII IIIIIIIII1111Iiliiiilllll SATISFACTORY DETERMINATION! Applicant's water supply appears adequate to meet needs of its intended use. Note: Mis determlbetlm does not address aaequaey of the diatributScn system, guazentes m adequate supply of water SMelinitely into the future, of quarmtee Compliance with all applicable w E water resource requ- latlma. _ UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade— quate to meet needs of its intended use for the following reason(s) : HEALTH INSPECTOR DATE