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Water Availability Verification Goldendale Office Klickitat County Health Department White Salmon Office 228 West Main Street 501 NE Washington St/ PO Box 159 MS-CH 14 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] RCW 19.27.097 requires proof of potable water prior to issuance of building and placement permits. Submittal of the following materials will all the Health Department to determine if you water system meets potable water requirements in Klickitat County. PLEASE NOTE: This application is a service offered by the Klickitat County Health Department and may be used to help lending agencies, real estate agencies, and sellers determine if the water supply serving the residence being sold meets Klickitat County standards. The water system review is a snapshot of the water supply on the day the Health Department conducts the review or inspection. The Health Department does not imply or warrant the future condition of the water system under review. Please submit the following during our business hours: Monday through Friday, 8 am to 5 pm. If this application is for a building permit, please notify the front desk or the sanitarian. 1. Complete application with payment of all applicable fees. There is a $50 fee with this application 2. Submittal of a well tag or well log id#. Well logs can be found online at the state department of ecology’s website; http://www.ecy.wa.gov/programs/wr/wells/wellhome.html/ 3. Results of a bacterial water analysis from Klickitat County Health Department within the last 12 months or a lab using EPA standard methods 4. Results of a nitrate water analysis from Klickitat County Health Department within the last 12 months or from a lab using EPA standard methods 5. Results of a 4 hour pump test if the well report indicates a water yield less than 5 gallons per minute 6. Verification of water rights if 5000 gallons per day are being utilized, or if you are using surface water as a source PLEASE NOTE: If you would like a well site inspection, please notify the sanitarian. If a well house is plan to be built around the well head, a building permit might be needed. Please contact the building department to confirm if a permit is needed or not. 1-[PHONE REDACTED]. ---PAGE BREAK--- Water Availability Verification Goldendale Office Klickitat County Health Department White Salmon Office 228 West Main Street 501 NE Washington St/ PO Box 159 MS-CH 14 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] The application below is for INDIVIDUAL WATER SYSTEM REVIEW ONLY. This application is required to meet WAV requirements for Klickitat County. When you submit this application for review, please include your $50 fee. PROPERTY INFORMATION Parcel Number: Lot Size: Site Address: City: State: Zip: CONTACT INFORMATION Name: Phone: Mailing Address: City: Sate: Zip: Email: Source Type: Well Spring Other: Locked Gate? Yes No Key or Code Location: PLEASE PROVIDE THE SETBACK DISTANCES FROM YOUR SOURCE TO THE LISTED POTENTIAL SOURCES OF CONTAMINATION. SEPTIC TANK NEIGHBORS SEPTIC TANK DRAINFIELD NEIGHBORS DRAINFIELD DRAINFIELD RESERVE AREA NEIGHBORS RESERVE AREA HOME CLEAN OUT NEAREST COUNTY OR STATE ROAD CESSPOOL OF PRIVY UNDERGROUND STORAGE TANKS RAILROAD TRACKS NEAREST BODY OF SURFACE WATER ANIMAL HOLDING AREA MANURE LAGOON OR PILE Reviewed By: HEALTH DEPARTMENT USE ONLY Bacteria Results Lab Satisfactory Unsatisfactory Nitrate Results Lab mg/L: At the this time of review: Meets minimum water quality standards DOES NOT meet minimum water quality standards