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Home My WebLink AboutWAT Application - 10/3/2000 MASON COUNTY DEPARTMENT OF HEALTH SERVICES Personal Heath Environmental Health —� • PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 BELFAIA(360)275-4467&4468 Application for Determination of Adequacy Instructions _ imiet.FmO. No determination can be made until Part 1 is fillycompleted. Complete otdy oporbon of part applying to the type of water system tdiliztd- ouplauds hCdfor,with attachments to the bealth department for renew_ PART 1: Applicant/Parcel Identification Natne of Applicant R a r w,o h l Date clD C 4 . 3 , ;mac» Mailing Address �361 C st SR l06 Telephone 3Go- T'74r- '2363 Assessor's Parcel Number 3 2 314!1 Do o >♦O e o Water System Check One): geason forApplication Check One publiclCommunity Water System(2 or tame Building permit wnnecaons) ❑ Land use application,if so.. ❑ Individual water source(one cormection),if so.. ❑ Division of land ❑ Well ItofPatrcels7 ❑ Spring/surface water SPH9= ❑ Other(explain) ❑ Boundary fine adjustment ❑ Other(explain) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adequacy: Public Water S stem rt�ter e of Water System wn.+ Facility Inventory(WFI)Ntmt O O '� S 1 / The water purveyor has filed a letter granting blanket hookups to this water system. ..G p' I am the manager of this water system. The water system has been approved for on services. 'There are T presently connections m ose. This will be the connection. is water system is able and willing to provide water to this(these)ru cGons wr out exceeding the limits of the water system or any limits set by state and local regulation. r ` Signature of Water System lM�anager rz Date to`S-) N.. ti.a ,fL',t fi 1 f3 IS H:tWDATAWRCfflVMWA7EPAW NP llpdeto:Me,&22.1999 W 7 t-fr 1A C--e Individual Water WeU a Water well report(attach to application) Depth (L ❑ Well capacity test(attach to application) gpm and Well capacity tests are often performed by the well driller at the time the well is constructed Ter, resultsh'am these,esis are noted on the water well report Results from!here tern will be accepted Ifthe water well report cannot be located by the applicant or ifthe water well report does not have a capacity test, a well capacity test, which provides stabilization ofdrawdown and recovery data, must be performed by a licensed contractor. ❑ Satisfactory bacteriological test(mach w appumian) Individual SpriftZSwface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection o 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 prsar to determination of adequacy. i 1 Departmental use only. Do not write below this line. PART 3: 1: ❑ SA .. .: 'u, ne.9.:c#'_ts:t!..ledPre: This determination does not address adequacy the dish ibutlon system, gran'antce an adequate supply ojwater indefinitely into the fiaure, or guarantee compliance with all applicable IVDOG water resource regulations_ UNSATISFACTORY DEI ERMINATION:. 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 H iWDATAURCHIVDWAT6 Dl.WP Update:March 22.19 STATE OF WASHINGTON DEPARTMENT OF HEALTH WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION:HEAD INSTRUCTIONS ON BACK OF GOLDENROD COPY N Ins"D ne an n NIwaeE,aampla WIN W m)ae - - DATE COLLECTED TIME COLLECTED WUNTY.NAME TT(((YPE OF SYSTEM IF PUBLIC SYSTEM,COMPLETE; �B C- .' CIRCLE I.D.ZI pem.wWl,wH.c., NAME OF SYSTEM /r / SPECIFICLOCATIONWFERESA1, LECOLLFCTED TELEPHONENO "_ - DAY( � — Z 3�7 c EVENING(44y) SAMPLE COLLECTED BY:(Na.)'. ,:;: ,, SYSTEM OWNERMAGR:NN..) SWRCEttPE nn.❑.uu GROUND WA UNDEfl SURFACE INFLUENCE ._ ❑SURFACE EWEUL FIELD ❑SPRING.'..❑INTER�SEDw ❑TIE OATH RTION SENDREPOryTTO:(PMnt Full Name,AE MpW Zy Ca) L�A� w, Lc�/' 9Li52. TY,IP,IKKO``nnFSAMPLEI�OnN awln Wecdwm) --4UROURE INKI NG WATER ❑CliM.W Favtlual_TDUI_F.) . ti:a"J1�.�—'.-.-__.'.—�jntreereaw ONer�--'+"•r^"-.. - ❑ REPEAT SAMPLE '- Prevbw cdibm Dresenw LRE Y Date ❑RAW SOIlROE WATER SousY $ ❑NEW CONSTRUCTION w-REPAIR ❑ Fowl C.,z ❑OTHER(Speuly) REMARKS: USE ONLY)DRINKING WATER RESULTS ❑ UNSARSFACTORYCWMgms Present CDIA FACTO I. REPEAT ❑80MIpmwnl ❑EWIl bent SAMPLED ❑ Fe Mmnt ❑ Fe Iae ntREQUIR , OTHER UBORATORY RESULTS TOTAL COL(FORM_/1 W mI-' E.COLT_11WV 1 FECALCOLIFORM_lim m1 PLATE COUNT—Iml ANOTHER SAMPLE REOUKW SAMPLE NOTTESTED BECAUSE: _ TEST UNSUITABLE BECAUSE:- ❑3MnPHIooaH ❑ Co H.w g'w VAorg=itamr . ,r L - ❑TNTC ❑Inwmprere lwm ❑TurDq cWWre. ❑. . ❑ Ex.n derma - SEE REVERSE SIDE OF GREEN COPY FOR EAPLAtATION OF RESULTS LA"'.- INGITS) DATE,TIMERECEIVED flECEIVED BY y.' t,JVJ.t .r X'l DATEREPORTED 4BGMTGflY:. OCXA6i MN.Nt1. ' \nIATFR ftl IPPI IFR Cr'�'"