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Water Availability Verification (WAV) Goldendale Office Klickitat County Health Department White Salmon Office 115 West Court Street 501 NE Washington St/ PO Box 159 Box 103 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 allow the Health Department to review and determine if your water system meets potable water requirements in Klickitat County. This application is for private water supplies, not for connection to public water supplies or shared wells. This application must be completed by the homeowner. Once submitted for review all fees are non-refundable. Please submit the following with your application; 1. Complete application with payment of all applicable fees ($200). 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. Satisfactory results of a presence/absence coliform & E. coli bacterial water analysis from Klickitat County Health Department within the last 12 months or from a licensed water lab using EPA standard methods. 4. Satisfactory results of a nitrate water analysis from Klickitat County Health Department within the last 36 months or from a lab using EPA standard methods. 5. Results of a 4-hour yield test, if the well report indicates a water yield less than 5 gallons per minute. 6. Verification of water rights for domestic use if you are using surface water as a source. You must provide a copy of the source being recorded to the title of the property. Homeowner Information Parcel Number: Lot Size: Site Address: Name: Phone: Mailing Address: City: State: Zip: Email: I, the undersigned, hereby certify that the information provided is true and accurate to the best of my knowledge. I hereby assume all responsibility for the accuracy of the information contained herein. Homeowner Signature: Date: