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Home My WebLink AboutCOM2009-00040 - WAT Application - 5/8/2009 MASON COUNTY fy E I V E DEPARTMENT OF HEALTH SERVICES MAY ( 3 2009 Environmental Health Personal Health PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 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 of Applicant Harmony Hill-Edc Blegen Date 5-8-2009 Mailing Address 7301 E Hwy 106, Union 98592 Telephone 360-898-2363 Assessor's Parcel Number 322334400040 Type of Water System Check One): Reason for Ai3plication Check One): 0 Public/Community Water System(2 or mom 0 Building permit connecdons)^ ❑ Land use application, 8 so.. ❑ Individual water source(one connecr n), ❑ Division of land: if so.. Well #of Parcels? SPL Spring/surface water ❑ Boundary line adjustment ❑ Other(explain) ❑ Other(explain) "It you have more than one residence ❑ Replacement(please indicate name of water system connected to this well,check the Public box. below it 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 Harmony Hill Water Facility Inventory(WFI) Number: 00195 1 (write"none"for two party) ❑ 1 am the manager of this water system. The water system has been approved for services. There are presently connections)in use.This will be the connection. ® I am the manager of this system.This connection will be to upgrade or change the use of an existing connection on this system tic:recreational to full time).Please indicate on the following line the nature of this change: Re-build of existing building This water system is able and willing to provide water to this(these)connections)without exceeding the limits of the water system or my limits set by state and local regulation. ./ Signature of Water System Manager i `o ate 5-8-2009 Utz:April2006 Individual Water Well Water well report(attach to application)Depth ft. Well Capacity test(attach to application) gpm Qpd e well drilleroften performs well capacity tests at Me lime the well is Constructed. esu s from these tests are noted on the water well repon. Results rrom these tests will be accepted. Ifthe water well re ort cannot be locate dby the applicantorifthe waterwellreport does not have a capacity test,a well capacity test,which provides stabilization ofdmw-down and recoverydata must be edorme b a licensed contractor. Satisfactory bacteriological test(attach m application) Individual Springilturface Water WDOE permit (attach to application) Method of disinfection ❑ 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 o serve ons. AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT IN ADDITION TO PROVIDING THE ABOVE STATEMENT,THE APPLICANT WILL NEED TOARMNGE AN ON-SITE INSPECTION BY THE HEALTH DEPARTMENT PRIOR TO DETERMINATION OF ADEQUACY. Departmental use only. Do not write below this line. P : Health Department Evaluation (Staff Use Only) SATISFACTORY DETERMINATION: Applica is water supply a pears adequate to PART 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.Apn120% cc MASON COUNTY DEPARTMENT OF HEALTH SERVICES April 29, 2009 PO BOX 1666 Shelton WA98584 Shelton (360)427-9670 Fax (360)427-8442 HARMONY HILL Elma (360)4825269 7362 E STATE ROUTE 106 UNION WA 997592 Belfair (360)275-4467 Case No.: COM2009-00040 Parcel No.:322334400040 Dear Applicant: Your building permit will not be approved by Mason County Public Health until the following items are completed and received in our office. Application for water adequacy completed and signed by the water system manager. Please call me at(360)427-9670, ext. 279 if you have any questions. Sincerely, aav� Amanda Reynolds Environmental Health Mason County Health Services Comments: 412912009 1 of 1 COM2009-00040 rn ti 0 hnen06J 'YJ ^�� MASON COUNTY y DEPARTMENT OF HEALTH SERVICES April 29, 2009 PO BOX 1666 Shelton`uW A 98584 Shelton (360)427-9670 Fax (360)427-8442 HARMONY HILL Elms (360)4625269 7362 E STATE ROUTE 106 UNION WA997592 Belfair (360)2754467 Case No.: COM2009-00040 Parcel No.:322334400040 Dear Applicant: Your building permit will not be approved by Mason County Public Health until the following items are completed and received in our office. Application for water adequacy completed and signed by the water system manager. Please call me at(360)427-9670, ext. 279 if you have any questions. 1 Sincerely, i Amanda Reynolds Environmental Health Mason County Health Services I Comments: i 1 r i { 4/29/2009 1 of 1 COM2009-00040 3 f i