HomeMy WebLinkAboutWAT Application - 7/25/2005 r MA50NCOUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health - Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-"67
Application for Determination of Adequacy FAX(360)427-7798
Instructions
1. Complete Part 1. No determination can be made until Part I 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. 771
PART 1: Applicant/Parcel Identification
�L
t_ification
Name of Applicant Wit'WhWK �t/deRr'K� bate J14L V5 716C5
Mailing Address 5501 Uke&W l"y t K Telephone `r*.
Assessor's Parcel Number — -wwa 50 - 0000*
Type of Water System(Check One): Reason forApplicadon (Check One):
❑ Public/community,water system(2 or
/ more connections) )iC Building permit FLe?LAC.Br'vl?
li InQividual well(one connection) b Land use application, if so...
� Well ❑ Division of land
❑ Spring/surface water #of parcels?
❑ Other(explain) SPH2=
soli+'Pl Ak ❑ Boundary line adjustment
Q.EPLpaC-F,M Qi4-r ❑ Other(explain)
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated for adequacy:
Public Waters stem
Name of Water System
Water Facility Inventory (WFI)Number:
0 The water purveyor has filed a letter granting blanket hookups to this water system.
0 1 am the manager of this water system. The water system has been approved for services. There are
presently connections to use. This will be the connection. t-7'fi`s water system is able and
willing to provide 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
Update:March 22,1999
Individual Water Well
❑ Water well report(attach to application) Depth ft.
❑ Well capacity test(attach to application) gpm ¢pd
Thewellal,ifferoftenperibrm well capacity tests at t time the w is constructedTest resv is om
these tests are noted on the water well report. Results Pram these tests will be accepted. If the water
or well report cannot be located by the applicant ijt a water well report does not have a capacity
test, a well capacity test which provider stabilization of drawdown and recovery data, must he
performed by a licensed contractor
❑ Satisfactory bacteriological test(aaach to application)
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 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
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 (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 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
Update:March n,19