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KLICKITAT COUNTY PUBLIC DRINKING WATER SYSTEM APPLICATION This applicaƟon is required to show your connecƟon to a public water system. Please fill out completely. This form is NOT the correct form for a shared well or two party system. If you need a shared well applicaƟon, please ask the staff for assistance. Please be aware, there is a $25 processing fee for this applicaƟon. Property Tax Parcel # Plat Plat Lot Site Mailing Contact Mailing This secƟon to be filled out by your Water System Purveyor Public Water Public Water System ID # of Approved # of ConnecƟons Does your water system use any surface water source or use over 5,000 gallons per day from a groundwater source? If so, please provide you Water Right Permit or CerƟficate and the amount for acre/feet per year: Please circle your method for tracking water usage: 1. Source meter 2. Individual meters on each connecƟon 3. None of the above The above Public Water System is capable and willing to serve potable water to this addiƟonal connecƟon(s). The water system faciliƟes necessary to adequately provide such service to this site have been designed, approved, and installed per WAC 246‐290. The above Public Water System is not able to provide a source of potable water a the site for the following reasons: Water Purveyor’s Water Purveyor’s Mailing Water Purveyor’s Day Water Purveyor’s Night NOTE: Upon submiƩal, we will be evaluaƟng our records for source approval, one year saƟsfactory bacteriological sample history, saƟsfactory inorganic and nitrate sampling, complaint history, and enforcement acƟons. Klickitat County Health Department Klickitat County Health Department 228 W. Main St., MS‐CH 14 501 NE Washington St. / PO Box 159 Goldendale, WA 98620 White Salmon, WA 98672 (509) 773‐4565 or 1‐888‐291‐3521 (509) 493‐1558 or 1‐888‐267‐1199