HomeMy WebLinkAboutBLD CD Environmental Health Review - 4/30/2007 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
1 011,1plete Part 1. No datelrataation can be made until al It
GWAlptete only the poi of Part 2 applying to the tyk d(WIder' teM uit)zero.
PART 1: Applicant/Parcel Identification
NameofApplicant MARLOA1 RMNs Date 4-30 -07
hel)onr wa c?"T
Mailing Address ago E. e issu i ' Telephone _3i� It.2 - 541
Assessor's Parcel Number 3 a 1 3 11-319 D o l- ,t
Type of Water System Check One): Reason for Application Check One):
Public/Community Water System(2 or more 19 Building permit
connections)" ❑ Land use application,if so..
❑ Individual water source(one connection), ❑ Division of land
if so..
well #of Parcels? 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 boic 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 R e i"b ow .2 - PUlr rY t-
Water Facility Inventory(WFI) Number:
(write"none"for two party)
I am the manager of this water system.The water system has been appprov for a services.
There are presently i connection(s)in use.This will be the d— connection.
❑ I am the manager of this system. This connection will be to upgrade m change the use of an
existing connection on this system(ie:recreational to full mi Please indicate on the following
line the nature ofthis change'
This water system is able and willing to provide water to this(these)connection(s)without
exceeding the limits of the water system ormy limits set by state and local regulation.
Signature of Water System Manager Date 4 -30- 07
Update:Avid 2006
Individual Water Well
Water well report(attach to application)Depth ___ft.
Well capacity test(attach to application) gpm _ gpd
e n ero en pe orm$W911 WID804y tests at the time thewe Is constructed- Results
from these tests are noted on the water well repod. Results from these tests will be
accepted. lfthe water well report cannot belocatedbythe applicantori/the waterwell reppoort
does not have a capacity testa well cAparilytest, which provides stabilization ofdrawipwn
and recoverydata must be perform by a licensed contractor.
Satisfactory bacteriological test(anach to application)
Individual S rin /Surface Water
WDOE permit(attach to application)
Method of disinfection
O 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
RELAnONSN IP TO APPUCAfIr
IN ADDITION TO PROVIDING THE ABOVE STATEMENT,THE APPLICANT WILL NEED TO ARWWGE AN ON-SITE
INSPECTION BY THE HEALTH DEPARTMENT PRIOR TO DETERMINATION OF ADEQUACY.
Departmental use only. Do not write below this line.
PART3: 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 indefinitely into the future, or guarantee compliance
withal]applicable WOOE 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
1-peme Apw