HomeMy WebLinkAboutWAT Application - 11/23/1993 MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
427-9670
RECEIVED (206)FAX 427-8425
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APPLICATION FOR DETERMIN I (YYJJDEQUACY
Rwlead 09/01/92
HEALTH SERVICES
INSTRUCTIONS
1. Complete Part 1. No determination can be made until Par of is fullystempieteutllased.
er
2. Complete only the portion of Part 2 applying to the type
2. Submit completed application, with attachments to the health department for review.
3.
PART 1: APPLICANT/PARCEL IDENTIFICATION T '
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DATE
NAME OF APPLICANT ✓ . . �,.:{
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MAILING ADDRESS /- a. _O _Si<•^^r_%
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ASSESSOR'S PARCEL NUMBER
LOT
SUBDIVISION (If Applicable)
TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One)
U/ El Building Permit, Single Family Res
public/Community Water System ��
Building Permit, Commercial
❑ ,
Individual System, Drilled Well []
❑ Building Permit, Replace/Remodel
Individual System, Dug Well
Spring Land Use Application
Individual System, P Name
El Type _.
Individual System, Surface Water ❑
El Individual System, Other Other
PART 2-A: PUBLIC WATER SYSTEM
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NAME OF WATER SYSTEM BP�1-OI/' ��Q�?Y /<7YiCT
❑ rioaely filed a certifiO to Of water aaaynw with the health
1Te water pnr"eyor [tr thla ey-t® has pw
district.
wel for service
LJ 1 em uanager of the aLwe roferenced water eyetm• Tne water ayalinavca has�appto,•al to content to this water
connection, with -a covnxtione presently in nee. TRw °� Se en-Sa[mt with
both the water -yet®
llcmt tar tlo-satin purpoas kart'- property
-yetem. Service o[ watei to the [a-avtly in effent. water lines are a lines. to the appl
plm and Ne water i19Rt pe
line, or the eppllcant he made atie[actory arrevg®ant+ to mKeM the lines. p
sv;aarum OF sysm M MEa
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PART 2-B: INDIVIDUAL WELL
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WELL DEPTH Ft WELL CAPACITY
Gallons/Minute Gallons/Day
Well log is attached to this application
Well capacity test results are attached to this application
aofaa: wall capacity tests sts often performed by the wail driller at the time the veil is con-
atructed. Teat reaulte from had. testa are note, on the well log. Meulte fron these
testa will be aoceptad by the health departmest. If s —11 log caonot be located by the
applicant, a well capacity test =at be performed by a 1lceuad oontractcr. aaler or Pump
testa are accePtable, P—ided wtabiliretlun of draw-down had been aeamured and reworded.
❑ Satisfactory total COliform test is attached to this application.
PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER
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WDOE 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
SOTRa In addition to mvo idLp the apova statement, the applicant will need to arrange se en-site
Inspedtion by the health district prior to deteralnatloo of adequacy.
Rt 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.
Rote: Min detelminetlon does not sadtese adequacy of the dietributien ryates, guarantee an adequate supply
of waist indefinitely into the future, or guarantee comPllance with all applicable WOOS water resource regu-
lation..
UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade-
quate to meet needs of its intended use for the following reason(s):
SPECTOR DATE
Rev' •.. 99/01/92