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POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
APPLICATION FOR DETERMINATION OF ADEQUACY
Revised 09/01/92
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: APPLICANT/PARCEL IDENTIFICATION
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NAME OF APPLICANT DATE -a9- /F 9
MAILING ADDRESS j36/ lug filt CD 43f 4(1 L..2 4rC AITELEPHONE (aZ )�Q$ ?C 4
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t Y `, State zip
ASSESSOR'S PARCEL NUMBER e= 3.ga sn000 o ? r. ,a. a_ oftw._
SUBDIVISION (If Applicable) Lyisd e/Rid",?e .b/0 / LOT 4 -9
TYPE OF WAT R SYSTEM (Check One) REASON FOR A PLICATION (Check One)
'n Permit, Single Family Res
Public/Community Water System Building �3
Public/ y Y
I I Individual System, Drilled Well 1-7
Building Permit, Commercial
Individual System, Dug Well 0 Building Permit, Replace/Remodel
Individual System, Spring 0 Land Use Application
Name
El Individual System, Surface Water Type
El Individual System, Other Other
PART 2—A: PUBLIC WATER SYSTEM
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NAME OFA WATER SYSTEM J p ee 04It i5i;Al a 0_0,mo al I1y i 11146 WFI ID 4'5 7 9- '3
. 'i-' The water purveyor for this system has previogsly filed a certificate of •water adequacy with the health
district. ► i ,Er • ,p t q a 3
Cd' L service
I am manager of the above referenced water system. The water system has DOS approval for
connections, with j/ connections presently in use. The applicant has approval to connect to this water
system. Service of water to the applicant for domestic purposes is consistent with both the water system
plan and the water right permit presently in effect. Water lines are available to the applicant's property
line, or the applicant has made satisfactory arrangements to extend the lines. �J
SIGNATURE OF SYSTEM MANAGER ` f DATE //^ 9 i'�
.-_ 7
PART 2-B: INDIVIDUAL WELL
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WELL DEPTH Ft WELL CAPACITY
Gallons/Minute Gallons/Day
U Well log is attached to this application
I1 Well capacity test results are attached to this application
NOTES: Well capacity tests are often performed by the well driller at the time the well is con-
structed. Test results from these tests are noted on the well log. Results from these
tests will be accepted by the health department. If a well log cannot be located by the
applicant, a Well capacity test must be performed by a licensed contractor. Baler or pump
tests are acceptable, provided stabilization of draw-down has been measured and recorded.
1 1 Satisfactory total coliform test is attached to this application.
PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER
I I 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
NOTE: In addition to providing the above statement, the applicant will need to arrange an on-site
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.
Note: This determination does not address adequacy of the distribution system, guarantee an adequate supply
of water indefinitely into the future, or guarantee compliance with all applicable WDOE water resource 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 DATE