Lewis County Public Health & Social Services
Environmental Services Division
2025 NE Kresky Ave, Chehalis, WA 98532 ● Phone: (360) 740-1146 ● Fax: (360) 740-1245
PUBLIC WATER AVAILABILITY NOTIFICATION
WAN #: _________________ Development Permit No.: ________________________________________
Property Location: ________________________________________________________________________
Applicant’s Name: ________________________________________________________________________
E-Mail: _________________________________________________________________________________
Applicant’s Mailing Address: ________________________________________________________________
Street City Zip
Signature of Applicant: ________________________________________ Date: ________________
APPLICANT MARK AND COMPLETE ONLY ONE: CHOICE A or B
Option 1: Two service connection water supplies
(To be completed by applicant)
Two connections (At least one a non-dwelling unit) ID# ______ Two dwellings units on separate parcels
Two dwelling units on same parcel Two dwellings units one an ADU
Proposed connection location:
Tax Parcel # _______________________________________________ Lot # ________
Short/Large/Long Plat # ______________________________________ Lot # ________
Well lo
cation, the well supplying water for this permit is located on: (check one fill in the blanks)
Tax Parcel # ________________________________________________ Lot # ________
Short/Large/Long Plat # ______________________________________ Lot # ________
Signature of Applicant: ________________________________________ Date: ________________
DEPARTMENT USE ONLY:
Yes No The shared well WS# ___________ has met the requirements of LCC8.55 and is approved to supply water to two
connections as described in this document. This approval is not a certification of the current water quality.
Signature/Title: _____________________________________________ Date: __________________
Option 2: Public/Community Water Supply (To be completed by a water system purveyor)
System Name: _
_____________________________ ID # _______________ Group A or B: ____________
Membership/Account # _____________________________
This system is capable of and will supply water to: (check one fill in the blanks)
Tax Parcel # ________________________________________ Lot or Space #
Short Plat # ________________________________________ Lot or Space #
This property is located at the address listed at the top of this page. All fees have been paid and the connection is authorized
Si
gnature/Title: ____________ Date: _______________
Note: Water Connection Approval for a public water supply is valid for only one year from date of approval below:
DEPARTMENT USE ONLY:
Yes No This public water supply is in substantial compliance with WAC 246-290 Group A or LCC8.55 Group B and is
adequate/approved to furnish water to this connection.
Signature/Title: _____________________________________________ Date: __________________
Permit Technician: ____________ Reconnection: Yes ___ No ____ Previous WAN#: __________
S:\COMMUNITY DEVELOPMENT\Applications & Forms\Currently on Website
Updated January 2020
click to sign
signature
click to edit
click to sign
signature
click to edit
NOTE: Availability of water does not guarantee the granting of a building or sewage permit. We recommend
applying for a sewage permit or at least a site evaluation BEFORE a well is drilled. Unsuitable soils or site may
result in denial of sewage and/or building permits.
NOTE: High levels of perchloroethylene have been measured in the shallow aquifer in the vicinity of the
intersection of Hamilton and Labree Roads. The area of investigation extends west to Rice Road and east
approximately 1/3 mile along the Hamilton Road North. Drilling into the impacted aquifer could expose
drilling personnel to contaminated soils and water. Moreover, during construction of wells in close proximity
to the zone of contamination, proper sealing and isolation of separate aquifers is required and extremely
critical to prevent possible contamination of deeper aquifers and minimize potential liability. Therefore,
PRIOR TO ANY DRILLING IN THESE AREAS please contact EPA Region 10 @ 206-553-2709 for more specific
information about this area of concern.
NOTE: High levels of Volatile Organic Compounds have been measured in the shallow aquifer in the vicinity
of the intersection of Jackson Hwy and the Forest Napavine Road East. The area of investigation extends
within a 1 mile radius of the intersection. Drilling into the impacted aquifer could expose drilling personnel to
contaminated soils and water. Moreover, during construction of wells in close proximity to the zone of
contamination, proper sealing and isolation of separate aquifers is required and extremely critical to prevent
possible contamination of deeper aquifers and minimize potential liability. Therefore, PRIOR TO ANY
DRILLING IN THESE AREAS please contact Washington State Department of Ecology, at (360) 407-7115 for
more specific information about this area of concern.
S:\COMMUNITY DEVELOPMENT\Applications & Forms\Currently on Website
Updated January 2020