HomeMy WebLinkAboutWAT Application - 11/10/2008 MASON COUNTY
DEPARTMENT Of HEALTH SERVICES _
Environmental Health _ Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)4279670
BELFAIR(360)2754467
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 ofApplicantGle%K :Fknes Date Z��eQp
Mailing Address /A f g 1>'w c S+ Telephone 8!2
Assessor's Parcel Number -So• Z�Sa Sa 200/Gk-
Type or Water System Check One): Reason forA lication Check One):
Public/Community Water System(z or more o Building permit
eonnecaonsr ❑ Land use application, if so..
❑ Individual water source(one connection), ❑ Division of land:
if so-
Well #of Parcels? SPL
Sprang/surface water ❑ Boundary line adjustment
❑ Other(explain) o Other(explain)
"If you have more than one residence ❑ Replacement(please indicate name of water system
connected to this well,check the Public bom 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 LA "Tt^
Water Facility Inventory(WFI) Number:
(wnte"none for two party) s )
15;t I am the manager of this water system. 77te water rystem has been a roved lmQ6S`services.
There are presently A4�wr necfon(s)in use.This will be the fyconnection.
❑ 1 am the manager of this system.This connection will be to upade or change the use of an
existing connection on this system(is:recreational infuB timer,lease indicate on the following
line the nature of this change:
This water system is able and willing to provide water to this(these)connections)without
exceeding the limits of the water system or any limits set by state findlocal regulation). �10
Signature of Water System Manager IZC4'il `�L Date ///F/•Lf)
1lp&W A012006
Individual Water Well
Water well report(attach to application)Depth ft.
Well capacity test(attach to application) glom gpd
e we n er n perlocrus wall capacity tests at the time the we is constructed. Results
from these tests are noted on the water well repof Results from these tests will be
accepted. lffhe water well re of cannofbelocaletlbytheapplicanf orfffhe waterwellrepod
tloes not have a capacity fast,a well capacdy test,which provides stabilization of draw-down
and recrove tlata must be erlormetl b a licensed conftactor
Satisfactory bacteriological test(aeac to aWLiMbon)
Individual SpringlSurlace Water
WDOE permit(attach to application)
Method of disinfection
❑ I have reason to believe that this water source can provide at least 800 ggallons ppeer day and/or
provides water at a rate of 2 gallons per minute based on the following observa,ons.
AUTHOR OF STATEMENT DATE
REIATIONSHP TO APPLICANT
IN ADDITION To PROVIDING THE ABOVE STATEMENT,TIE APPLICAW WU_NEEOTOARRANGE AN ON-SITE
INSPECTION W THE HEALTH DEPARTMEW PRIOR TO DETERMINATION OF ADEOWCY.
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. O _ V tK G 4 If"
'this determination does not address adegJacyofthe dishibufion 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 (s):
REVIEWER'S SIGNATURE DATE / —/,Z-D 9
U,d Ail2W6