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Klickitat County Department of Public Health 228 West Main Street, SUITE B, Goldendale, WA 98620 * VOICE (509) 773-4565 * FAX (509) 773-5991 501 NE Washington Street, PO Box 159, White Salmon, WA 98672 * VOICE (509) 493-1558 * FAX (509) 493-4025 Director of Public Health: Kevin Barry Water Availability Verification RCW 19.27.097 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. NOTE: The Water System Review application is a service offered by the Klickitat County Health department to help lending agencies, real estate agencies, and sellers determine if the water supply serving the residence being sold is safe and reliable, and meets disclosure requirements. 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. Goldendale Office 228 W. Main MSCH-14 Goldendale, WA 98620 Phone (509) 773-4565 Fax (509) 773-5991 White Salmon Office 501 NE Washington White Salmon, WA 98672 Phone (509) 493-1558 Fax (509) 493-4025 Please submit the following during our 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#. THIS CAN BE OBTAINED AT: http://www.ecy.wa.gov/programs/wr/wells/wellhome.html/ 3. RESULTS OF A BACTERIAL WATER ANALYSIS FROM KLICKITAT COUNTY HEALTH DEPARTMENT OR A WASHINGTON STATE CERTIFIED LABORATORY TAKEN WITHIN THE LAST 12 MONTHS 4. RESULTS OF A 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 THE WELL REPORT INDICATES A WATER YIELD OF LESS THAN 5 GALLONS PER MINUTE 6. WATER RIGHTS IF 5000 GALLONS PER DAY ARE BEING UTILIZED, OR IF YOU ARE USING SURFACE WATER AS A SOURCE. Water rights can be obtained through the Department of Ecology: http://www.ecy.wa.gov/ 7. PAYMENT OF ALL FEES: Including $50 for the well application, $30 for the bacteriological analysis, and $20 for the nitrate analysis ***NOTE: IF YOU WOULD LIKE A WELL SITE INSPECTION, YOU MUST SCHEDULE AN APPOINTMENT*** If a well house is to be built around the well head, a building permit might be needed. Please contact the building department to confirm that a building permit is needed or not. 1‐800‐583‐8078 ---PAGE BREAK--- INDIVIDUAL WATER SYSTEM REVIEW APPLICATION Owner(s) or Interested Mailing Contact Phone Site City Tax Parcel Lot # Parcel Size Source Type: Well Spring Locked Gate? Yes No Gate Code/Key Depth The well produces_______gpm The spring produces________gpm NOTE: If your source of drinking water is a spring, you will need to provide a copy of your water rights. Is your source on the highest ground possible? Yes No Is your source protected from flooding, or subsurface drainage? Yes No The nearest property line is if less than 100’ has your neighbor been notified? Yes No Sewage Disposal method: On-site sewage system Public Sewer Please provide the setback distances from your source to the listed potential sources of contamination. SEPTIC TANK NEIGHBOR’S SEPTIC TANK DRAINFIELD NEIGHBOR’S DRAINFIELD DRAINFIELD RESERVE AREA NEIGHBOR’S RESERVE AREA PIPE FROM HOUSE TO SEPTIC TANK NEAREST COUNTY OR STATE ROAD CESSPOOL OR PRIVY UNDERGROUND STORAGE TANKS RAILROAD TRACKS NEAREST LAKE/STREAM/SWAP ANIMAL HOLDING AREA MANURE LAGOON/PILE OR BARN Directions to Site: Health Department Use Only Bacteria Results Satisfactory Unsatisfactory Nitrate Results At the time of review the supply: Meets minimum water quality and adequacy standards Reviewed Comments: DOES NOT meet minimum water quality and adequacy standards