HomeMy WebLinkAboutWAT2025-00117 - WAT Application - 6/2/2025 MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
Environmental Health Personal Health
PO BOX 1666 SHELTON,WA 98584
LOCAL(360)427-9670
BELFAIR(360)275-4467
FAX(360)427-7798
Application for Determination of Adequacy
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
Name of Applicant "T. ),use�� Date 672
Mailing Address '`1 31 6 'f-- AVE: A'2 My Telephone 360 • `i 763 - 12-3 3
tr' `fr.f5(G
Assessor's Parcel Number '3 2► 2 -7 - 5 -5- U<) ob L t_ m r v,e_.L 4
►S 1 Du;Ic 4. Le:71-6
T pe of Water S stem Check One : Reason for Ap lication (Check One):
Public/Community Water System (2 or more Building permit
connections)" ❑ Land use application, if so..
o Individual water source(one connection), ❑ Division of land:
if so..
Well #of Parcels? SPH -
Spring/surface water
o Other(explain) o Boundary line adjustment
** If you have more than one residence o Other(explain)
connected to this well, check the Public box.
PART 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of Water System � Kc L• jt, c,,
Water Facility Inventory (WFI) Number: LI y(S7T
(write "none"for two party)
I am the manager of this water system. The water system has been approved for /3 97 services.
There are presently RAT connections in use. This will be the connection. I his water
system is able and willing to provide water to this(these)connections wit ou exceeding the limits of
the water system or any limits set by state and local regulation.
Signature of Water System Manager (3) -1{,UtL1 Date 6-3-2OZ
Updatc:Dcccnibcr 2005
Individual Water Well
Water well report(attach to application) Depth ft.
Well capacity test(attach to application) gpm gpd
The well driller often performs well capacity tests at the time the weil is constructed. <esu�s
from these tests are noted on the water well report. Results from these tests will be
accepted. If the water well report cannot be located bythe applicant or if the water well report
does rec dataoovery pmust be performed by a licensed contractor.rr ll py test, which rs stabilization of draw down
and
Satisfactory bacteriological test(attach to application)
Individual Sarin•/Surface Water
WDOE permit (attach to application)
Method of disinfection
❑ I have reason to believe that this water source can provide at least 800 gallons per day and/or
provides water at a rate of 2 gallons per minute based on the following observations.
AUTHOR OF STATEMENT DATE
RELATIONSHIP TO APPLICANT
IIN NSPDEDCTION BY THETHEOHEDING THE ABOVE ALTH DEPARTMENT PRIOR rT, THE APPLICANT WILL NEED TO DETERMINATION F ADEQUACY.
O ARRANGE AN ON SITE
Departmental use only. Do not write below this line.
PART 3: Health Department Evaluation (Staff Use Only)
X SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to
meet the needs of its intended use.
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 regulations.
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 5A, DATE 7/3/25
Update:December 2005