HomeMy WebLinkAboutWAT Application - 7/25/2005 (2) 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. Complete Part 1.No determination can be made until Part 1 is Pollycomole[ed
2 Complete only the portion.of Part 2 applying to the type of water system utilized
3 . Submit completed lication,with attachments to the health department for review.
PART 1: Applicant/Parcel Identification I
Name of Applicant W^MAK @tRl§vMQAIb'1� L�i1Zl�jate V14 J -71 JAC5
Mailing Address 550' Uk11e14/ WV6 Telephone 4 468 Z01
Assessor's Parcel Number XJJ, 50 ' 0000�-
Type of Water System(Check One): Reason for Application (Check One):
❑ Public/community water system(2 or
/ more connections) X Building permit F-e-VLACC�,,Ve
tl In ividual well(one connection) ❑ Land use application,if so...
ti Well ❑ Division of land
❑ Spring/surface water #of parcels?
❑ Other(explain) SPI42_-
&I L-0114 ❑ Boundary line adjustment
REPLAC*N'v 1?i J.L? ❑ 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
Water Facility Inventory (WFI)Number:
❑ The water purveyor has filed a letter graining blanket hookups to this water system.
❑ I am the manager of this water system. The water system has been approved for services. There are
presently connections muse. This will be the connection. m-7Tiswater system is able and
willing to proven a water to this(these)connections without t exceeding the limits of the water system or any
limits set by state and local regulation.
Signature of Water System Manager Date
Updates March 22,1999
` Individual Water Well
❑ Water well report(attach to application) Depth ft.
❑ Well capacity test(attach to application) gpm gpd
T ewe i er oftenper arms we capacity tests art ¢timer ewe is constructed Testresvts om
these tests are noted on the water well report. Results from these tests will be accepted. lfthe water
well report cannot be located l the applicant or rf the water well report does not have a capacity
test, a well capacity test, which provides stabillmtion of drawdown and recovery data, must be
e ormed b a licensed contractor
❑ Satisfactory bacteriological test(mach a applira j.)
Individual Spring/Surface Water
❑ WDOE WR permit(attach to application)
❑ Method of Disinfection
❑ I have reason to believe that this water source can provide at least 80o gallons per day and/or
provides water at a rate of 2 gallons per minute based on the following observations
Author of Statement 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 of adequacy.
Departmental use only. Do not write below this line.
PART 3: Health Department Evaluation (Stag 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 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)i
REVIEWER'S SIGNATURE DATE
Ilpde .Mardi 22,1999