HomeMy WebLinkAboutWAT Application - 2/22/2022 willillillilillllllllIIIIIIIIIIIIIIIIIIIIIIillillillillillillI
MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTONr WA 98584
(206) 427-9670
FAX 427-8425
APPLICATION FOR DETERMINATION OF ADEQUACY
aevived 09/01/92
INSTRUCTIONS is fully omoleted.
Po of Part 2 applying to the type of water eyatem ut lLlzed.
1, complete Part 1. No determination can be made until Part �—
2, Complete only the p with attachments to the health department for review.
3, Submit completed application,
PART I. APPLICANTIPARCEL IDENTIFICATION
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NAME OF APPLICANT TELEPHONE
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TELEPHONE Z-�
MAILING ADDRESS / b.
ASSESSOR'S PARCEL NUMBER
9 Coti D� � 7 Lox
SUBDIVISION (I f Applicable) AA a One)
TYPE of WATER SYSTEM (check One)
REASO F APPLICAT
flu ing , Single Family Rea
❑ public/Community Water System � ��
Bui]aLng Permit, Commercial
❑ stem, Drills V
Individual 5y Re lace/Remodel
ding Permit, P
❑ Individual System, Dug Well
Land Uae Application
❑ Individual System, Seri Name
Type
❑ Individual Sy ate , Surface Water
❑ Other
❑ Individua yetem, Other -
PART 2-A' UBLIC WATER SYSTEId
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NAME OF WATER SYSTEM edognacy with the health
The water potvayo[ mr tole eyst® has previously filed a certificate of 'water
district.
tam na. DDa approval for __.
service
❑ them The water eye 1 to connect to thin Ovate[
I am menegez of the aEwe referenced water
in sea. The applicant has approve h the water system
connections, with concertiove pro is consistent with Eon
water to the applicant fox domeeCle purposes vailarls to the applicant's propetty
eyatem. Service of to a
plan and the water right pateit patiently in arrargeffect Water lines
the liven.
line, or the applicant has made satisfactory airangemenis t
DATE -�
PART 2-B: INDIVIDUAL WELL -
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WELL DEPTH
--�It WELL CAPACITY
Gallon, Gallon— ,/pay
Well log is attached to this application
Well capacity test results are attached to this application
aorta: Well
capacity taste are often parformod by the Wall dnillar at the time the Well
Is don
-
etiucred. Teat result from neae testa are aotetl on the Wall log Reaultatram thee,
teats will he accepted by the health dapartaant. rf a Wall lag cannot be located by the
applicant, a well capacity test at bs psrformsd M testa era a c a licensed conttactor. Baler or pump
eptabls, provided atabillration of draw-down has base ndwa'rwd and raderded.
Ej Satisfactory total coliform teat is attached to this application.
PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER
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WOOS permit is attached to this application
I have reason to believe the spring
adequate water its intended purpose. pro Thissbelief ised asebasedr On thewlfollsuply
owing
observations:
AUTHOR OF STATEMENT
DATE
RELATIONSHIP TO APPLICANT
wd1 : in addition to providing the above atatenest, the epplies.t the arrange an on-site
will naafi w lospection by e health dlstrlct prior to detereddetion of adequacy.
PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only)
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SATISFACTORY DETERMINATION: Applicant's water supply appeare adequate to meet
needs of its intended use.
Nate: This determination does not addreae d,.a, of the di.tzibution ryat®, guarantee an adequate supply
Of water SMef
latlone. lnitely into the future, or guarantee compliance with all applicable W,,N Water raeouxce rsgu-
UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade—
quate to meet needs of its intended use for the following reason(s) :
-"TH INSPECTOR
-'— ------ DATE