WATER USE

Water Use Questionnaire

Please complete as thoroughly as possible. If you are unsure, you may leave the field blank.

[1] Name

Your Name: *

[2] Mailing Address

Mailing Address: *

City: *

Select a State: *

Zip Code: *

E-mail: *

Telephone No.: *

[3] Water Quality Desired (select one) *

Indoor domestic only (275 gallons per day, on average)
Indoor domestic and some irrigation (300 gallons per day, on average)
Indoor domestic and irrigation (350 gallons per day, on average for domestic use and irrigation of 500 square feet)

[4] Well status (select one): *

Future well (not yet drilled)
Existing well

If existing well, well tag number: *

The well tag is provided by the Department of Ecology and is riveted to the well casing of an existing well. The well tag shows a unique well identification number.

[5] Water use status (select one): *

Existing residence:

Date of subdivision or building permit application (if known): *

Date residence was completed: *

New construction:

County Building Permit/Subdivision Application Number: *

[6] Water System Classification (select one) *

Single connection
Shared well (2 connections):

Parcel No. where the well is located: *

Group B Public Water System (3-14 connections):

Name of system (if known): *

Parcel No. where the well is located: *

Group A Public Water System (15 or more connections):

Name of system (if known): *

Parcel No. where the well is located: *

Administrative

Parcel #: *

Owner Name: *

Owner Address: *

Link #: *

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