HomeMy WebLinkAboutWAT Application - 3/13/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE tOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
APPLICATION FOR DETERMINATION OF ADEQUACY
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INSTRUCTIONS
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only th4 portion of Part 2 applying to the type of water Byetem utilized.
3. Submit completed application, with attachments to the health department for review.
PART 1: APPLICANT/PARCEL IDENTIFICATION '
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NAME OF APPLICANT L)d.V CAF S-t fp'��,ly/// S P Al DATE -ILI
MAILING ADDRESS SI (� l u/r/��, Al , W. TELEPHONE ( 275) Zt/9' C
ASSESSOR'S PARCEL NUMBER / 2 3 30 ,�<{ 0 p 6 �- O
SUBDIVISION (If Applicable) J ! / / LOT >
TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One)
Public/Community water System Building Permit, Single Family Res
Individual System, Drilled Well Building Permit, Commercial
Individual System, Dug Well ❑ Building Permit, Replace/Remodel
El 1 Individual System, Spring 0 Land Use Application
❑ Name
Individual System, Surface Water Type
❑ Individual System, Other 0 Other
PART 2-A: PUBLIC WATER SYSTEM -
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NAME OF WATER SYSTEM 13 e0. YC( S COVL' S)xd PM WFI ID
P1The water purveyor for this eystas has previously filed a certificate of Water adequacy win "a health
dlstrict.
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I a secager of the shove referenced water syates. Tha aster agates Me ire apP n,al for rule.
m,u dctions, WSN wectione presently in use. The applicant has approval to comect to thiswater
eyetam. Service of rater to the ...licent for dmaatic purposes is emal.tant in both the water Byetem
Plan and the Water right Potm1t presently in affect. Metar lines are avallahle to the applicant's property
line, or Ne applicant Me made satisfactory arraNseents to extend the lines.
8IGM11mE OF SYSTn1 MAImurs ___ OMIT
PART2"B: INDIVIDUAL WELL
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WELL DEPTH Ft WELL CAPACITY
GoLllons/minute Gallons/Day
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Well log is attached to this application
Well capacity test results are attached to this application
a 8; W-11 ca Wirl testa are often partormd by the .11 driller at the time the Well Se con-
strocted. Teat results from these taste are noted an the sell IN. AesulLF fro these
tests will be acceptel by the health depertmnt. If a se11 lop cannot be located by the
Applicant, a Wall capacity teat suet be performed by a licensed contractor. aslar or p
tests era ecalfabl., provided atebiliretlon of dray-down hea been maaured and recorded.
Satisfactory total coliform test is attached to this application.
PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER
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HUGE permit is attached to this application
I have reason to believe the spring proposed as the water source will supply
adequate water its intended purpose. This belief is based on the following
observations:
AUTHOR OF STATEMENT DATE
RELATIONSHIP TO APPLICANT
.BYTE: In addition to providing the eM . atatennot, the applicant will need to arrange an on-mite
inspection by the health district prior to determination of adequacy.
PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only)
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SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet
needs of its intended use.
pore: This determination does cot eddrees eda sar, of the distribution " t., guarantee an adequate supply
Of Water indefinitely into the future, or puarantw complience with all applicable g Watar rsenores regu-
lations,
UNSATISFACTORY DETERMINATION: Applicant's water Supply does not appear ade-
quate to meet needs of its intended use for the following reason(s)-
HEALTH INSPECTOR "I/ �/ DATE