Laserfiche WebLink
OFFICIAL USE ONLY <br />Review of Application: TRACKING #: <br />Project is proposing to utilize an individual well with 1 connection? <br />❑ Yes <br />❑ No <br />IF NO: Is the proposal a 2 -parry shared well or a group system? <br />❑ Yes <br />❑ No ❑ N/A <br />Does the application provide a valid well ID number for the proposed project? <br />❑ Yes <br />❑ No ❑ N/A <br />Project is in the Upper Kittitas County boundary as defined by 173-539A WAC: <br />❑ Yes <br />❑ No <br />Application materials for the proposed project are attached and complete: <br />❑ Yes <br />❑ No <br />• A copy of the well log OR a 4 -hour draw down test: <br />• A current passing (within < 1 year) bacteriological and nitrate (within <_ 3 years) well water test: <br />• Site map identifying the location of the proposed project and well location <br />A Determination of Water Budget Neutrality or other proof of mitigation was provided. <br />❑ Yes <br />❑ No ❑ N/A <br />❑ Determination of Water Budget Neutrality from Washington State Department of Ecology; OR <br />❑ A copy of the water right associated with the source of water; OR <br />0 Kittitas County Interim Water Program Mitigation Certificate <br />Has proof of mitigation been recorded on Deed/Title with Kittitas County Auditor? <br />❑ Yes <br />❑ No ❑ N/A <br />Water Quality Technology/Storage Required: <br />❑ N/A <br />EVALUATION NOTES: <br />DATE: NOTES: <br />DATE: NOTES: <br />DATE: NOTES: <br />FINAL EVALUATION: REVIEWER: DATE: <br />Based on the information provided in this application and to the best of my knowledge and ability at this time: <br />0 Requirements for adequate water supply determination appear to be complete and satisfactory*t <br />❑ The request for adequate water supply determination is not complete or unsatisfactory and therefore has been denied*t <br />Notes: <br />*The Building Official makes the final determination on the issuance of a building permit per RCW 19.27.097 <br />t KCPHD does not make determinations regarding an applicanCs legal right to ground water or the validity of WAC 173-539A nor does KCPHD have the authority to perform such actions. <br />ADEQUATE WATER SUPPLY DETERMINATION FEE $305 <br />Total Fee Due: = Receipt #: <br />***The adequate water supply determination approval remains valid only if the facts asserted and <br />governing law do not change, and expires within 1 year of issuance. All applicable fees may be non- <br />refundable. *** <br />Page 5 of 5 <br />