HomeMy WebLinkAboutWEL92-0019 - BLD Water Adequacy - 9/2/1994 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Personal Health
Environmental Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467&4468
Application for Determination of Adequacy
Instructions
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Complete Par[I No dettatmahpn can be made uggi Part 1 w filly complete
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PART 1: Applicant/Parcel Identification
Name of Applicant Torn t Ug r Date -Ab-00
Mailing Address olLk Mr W Telephone-32 - Sorb'
gSiS' S
Assessor's Parcel Number 112 30 7S' 9 OO Sa —
e of Water S�sterrt Check One : Reason or [ieation Check One
Public/Commmity Water Syamal(z m n X Building permit
¢ wm�edlom) ❑ Land use applieation,if so..
❑ Individual water states(oM—dion),if sn" ❑ Division of land
R Well #of Parcels?
❑ Spring/surface water SPW—
❑ Other(explain) ❑ Boundary line adjustment
❑ Other(explma)
PART 2: Water System Information
complete the section appropriate for the type of water system being evaluated for adequacy:
Public Water S stem
t S
Name of Water System""
Water Facility Inventory )N EL 6J A 5L
❑ The water purveyor h�led a letter granHng`6laaket hop ps to this water system.
�, 'ben roved for�services. There are
❑ Ism the mapager of this water stem. The water system has a�nn water system is able and
presenay J wmecaons m use. "Otis will be the 2L i the water system or any
willing to proves water to this(these)connections 't owe B
limits set by state and local regulation.
Date
Signature of Water System Manager
B m0
iEIPDATAWRCIUMIWATMD3.WP Update:March 2Z 19"
W - 7
' Individua!water wen �\
7ff7th-e
ll report(attach to application) Depth /SD ft.
e� city test(attach to application) t' gpm and
city tests are often performed by the well driller the time the well is constructed rest
m there tests are noted on the xater well report. Ulu from these tests will be accepted
rwell report cannot be located by the appli t r if water well report does not have test, a well capac;tes( which provides st bt a draw-down and recovery data,rformed by a licensed conhactor.
d✓ Satisfactory bacteriological test(mrxh to appii on)
Individual&rInjSurface Water
roMethend
DOE permit(attach to application)
of disinfection
ve reason to believe that this water source can provide at least 900 gaallons per day and/or provides
er at a rate of 2 gallons per minute baud on the following observations.
AUTHOR OF STATEMENT DAB
RELATTONSHIP TO APPLICANT
In addition to providing the above statement, the appplicant will need to arrange an on,site Inspection by
the health deparmmentprior,to determination ofadequaev
Departmental use only. Do not write below this line.
PARTS: Health Department Evaluation (siafiise only) d
SATISFACTORYDE7'ERNIINAI'ION: Applicant'swatersupplyappears adequatet
meet the need%.of its intended use.
.This determination does not address adequacy of the dish ibution system, baiarantec
an adequate supply of water uide_finitely into the future or gaiarantec compliance
with all applicable 4,190f water resource regulations
p .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
Hi WDATAUECHIVEIWATEEAD3.WP Update:March 22, 1999
GUDSdMASONCOUNf'Y'
$S DEPT. OF HEALTH
�1 5D. Field Sheet for SWG#
Applicant Name:�'17ci(1 l.()YIt
Absence of critical area verified on subject property: ,rl �"
Yes No
Steep Slopes >
P kk� 15%
2. Water �
a. Wetlands
b. Streams
C. Lakes
d. Ponds —� 8
e. Saltwater
r
M
't rian' Signatur Dat
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
MASON COUNTYBLDG.. III, 426 W. CEDAR ST.
P.O. BOX 1666, SHELTON, WA 98584
360-427-9670, FAX 360-427--14�RP
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