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,1 k t t: t t j <br />i <br />Public Health Tracking#: <br />- De1) a: tmant <br />Date Accepted: <br />To Protect and Promote the Health and the Environment of the People of Kittitas County Accepted By: <br />FORM ADEQUATE WATER SUPPLY DETERMINATION FOR BUILDING PERMITS: <br />I/c INDIVIDUAL/SHARED WELLS (Interim Measure Dates) <br />J Incomplete applications, including applications without the proper documentation, will not be accepted. <br />KCPHD will return incomplete applications to the applicant. All applicable fees may be non-refundable <br />OWNER OF RECORD: <br />PHONE #: <br />MAILING ADDRESS: <br />PARCEL #: <br />CITY, STATE, ZIP: <br />E-MAIL: <br />PROJECT LOCATION: <br />EXISTING UNIQUE WELL ID#: <br />MITIGATION CERTIFICATE #: <br />PROJECT USE: <br />❑ New dwelling unit* with potable water <br />❑ Remodel that adds fixtures, and creates an additional dwelling unit.* <br />❑ Addition that adds fixtures, and creates an additional dwelling unit. <br />❑ Addition of potable water to a dry structure <br />Please describe project: <br />*A dwelling unit is defined as: "A single unit providing complete, independent living facilities for one or more persons, <br />including permanent provisions for living, sleeping, eating, cooking and sanitation." <br />Does the parcel currently have a structure with plumbing? ❑ YES ❑ NO <br />Does the well serve anotherparcel? ❑ YES ❑ NO <br />Please provide the following: <br />• Well log, reconstructed well log, or 4 -hour draw down well test <br />• Site map identifying the location of the proposed project and well location <br />• Current passing nitrate (within 3 years) and bacteriological (within 1 year) well water tests <br />• If shared well, please provide a recorded shared well users agreement <br />• Water Budget Neutrality Determination or other proof of mitigation <br />• Recorded Water Budget Neutrality Determination or other proof of mitigation on title with Kittitas County Auditor <br />Page 1of5 <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 />