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Connection to a Public Water System Goldendale Office Klickitat County Health Department White Salmon Office 115 West Main Street 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] RCW 19.27 requires proof of potable water before a building permit. Completing this application is will show you have an approved connection to a public drinking water system. This application must be returned to the Klickitat County Health Department for review & processing along with the $50 review fee. All fees are non-refundable. The bottom section is to be completed by your water system purveyor. Property Information Parcel Number: Lot Size: Site Address: City: State: Zip: Applicant Contact Information Name: Phone: Mailing Address: City: State: Zip: Email: THE SECTION BELOW IS TO BE FILLED OUT BY YOUR WATER PURVEYOR Water System Name: Water System ID#: Total # of Approved Connections: Total # of Connections Served: ☐ The abovementioned parcel has an active water meter and service connection with this public water system. The water system facilities necessary to adequately provide such service have been reviewed and approved in accordance to WAC 246-290. ☐ The water system facilities have been reviewed and the following conditions for service are required prior to final occupancy of the structure; Water Purveyor or Operator: Phone: Signature: Date: