Full Text
rev: 01182006 PROOF OF POTABLE WATER FOR INDIVIDUAL WELLS RCW 19.27 requires proof of potable water prior to issuance of building and placement permits. Submittal of the following materials will allow the health department to determine if your water system meets the potable water requirements. Klickitat County Health Department Goldendale Office White Salmon Office 228 W Main MSCH-14 501 NE Washington Goldendale, WA 98620 White Salmon, WA 98672 Phone (509) 773-4565 FAX (509) 773-5991 Phone (509) 493-1558 FAX (509) 493-4025 Business Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m. 1. COMPLETED APPLICATION FORM. 2. SUBMITTAL OF WELL TAG OR WELL LOG ID Obtained through: http://apps.ecy.wa.gov/welllog/ 3. RESULTS OF BACTERIAL WATER ANALYSIS FROM KLICKITAT COUNTY HEALTH DEPARTMENT OR A WASHINGTON STATE CERTIFIED LABORATORY TAKEN WITHIN THE LAST 12 MONTHS 4. RESULTS OF NITRATE WATER ANALYSIS FROM KLICKITAT COUNTY HEALTH DEPARTMENT OR A WASHINGTON STATE CERTIFIED LABORATORY TAKEN WITHIN THE LAST 12 MONTHS 5. RESULTS OF A 4 HOUR PUMP TEST IF WELL RPORT INDICATES A WATER YIELD LESS THAN 5 GPM 6. WATER RIGHTS IF GREATER THAN 5000 GPD IS BEING UTILIZIED. Water rights information can obtained through the Department of Ecology: http://www.ecy.wa.gov 7. PAYMENT OF ALL FEES ---PAGE BREAK--- rev: 01182006 INDIVIDUAL DRILLED WELL APPLICATION & RESULT FORM Owner(s) Phone: Mailing Address City Zip Contact Person Phone Project Description Site Address City Tax Parcel Number Lot # Well Tag or Well Log ID # Parcel Size Well site approval by: Licensed well driller Other Well Information: Driller: Date Completed: Depth (feet) The well produces gallons per minute (GPM). Located on the highest ground possible? Up hill from contamination? Protected from flooding surface, or subsurface drainage? Yes No Nearest property line feet, if less than 100’, has neighbor been notified? Yes__ No Sewage Disposal Information: _____On-site sewage system _____Public Sewer SETBACKS: DISTANCES FROM YOUR WELL TO POTENTIAL SOURCES OF CONTAMINATION: SEPTIC TANK NEIGHBOR’S SEPTIC TANK DRAIN FIELD NEIGHBOR’S DRAIN FIELD DRAIN FIELD REPLACEMENT AREA NEIGHBOR’S REPLACEMENT AREA PIPE FROM HOUSE TO SEPTIC TANK NEAREST COUNTY OR STATE ROAD CESSPOOL/PRIVY UNDERGROUND STORAGE TANKS RAILROAD TRACKS NEAREST LAKE/STREAM/SWAMP ANIMAL HOLDING AREA MANURE LAGOON/PILE OR BARN *The attached bacteriological and nitrate samples were taken from the water source on the aforementioned property. Owner/Agent Signature: Date: WATER QUALITY AND QUANTITY RESULT The individual drinking water system has been evaluated and found to be: Satisfactory Satisfactory, attached conditions: Unsatisfactory Health Department Approval: