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HomeMy WebLinkAboutWAT Application - 6/14/2004 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 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: ApplicantlTarcel Identification Name of Applicant m Date U.111.16g Mailing Address VO P,nx a199- S"K k-t W Telephone �- Assessor's Parcel Number 3,tjF,_q. 53. 15005 Type of Water System (Check One): Reason for Application (Check One): Public/community water system(2 or %TlBuilding permit more connections) ve-�New ❑ Private Two-Party ❑ Replace Existing Structure ❑ Individual well (one connection) ❑ Land use application,if so... ❑ Well ❑ Division of land ❑ Spring/surface water #of parcels? ❑ Other(explain) SPH2_- ❑ Boundary line adjustment ❑ Other(explain) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adequacy: Public Water System/Private Two Party Name of Water System PtAO I Water Facility Inventory(WFI)Number(enter"none"for Two-Party): i] The water purveyor has filed a letter granting blanket hookups to this water system ❑ I am the manager of this water system The water system has been approved for services. There we presently connections muse. This will be the connection.�'lus water system is able and willing to pro" to this(these)connections withoutout e�xcee t^g the limits of the water system or any limns set by state and local regulation. Signature of Water System Manager Date N:IWELLIWATMD3.WP.DOC Update:March 22,1999 Individual Water Well ❑ Water well report(attach to application) Depth R. ❑ Well capacity test(attach to application) gpm gpd e well drille,o en perjorms well capacity tests at t e time we is construct at resu a m these tests are noted on the water well report. Results from there tests will be accepted. If the water well report cannot be located by the applicant or if the water well report does not have a capacity test, a well capacity test, which provides stabilization of drawdown and recovery data, must be e armed b a licensed contractor. ❑ Satisfactory bacteriological test(anach w application) IndtWdual 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 o*) ❑ SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet the needs of its intended use. This determination does not address adequacy ofthe 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 111WEaUKATERAD3,Wr.DOC Updaw March 22,1999