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HomeMy WebLinkAboutWAT2024-00384 - WAT Application - 12/30/2024 WAT taT V 416 N.6°:3eaet MASON COUNTY shdtoe WA9ese4 COMMUNITY SERVICES sheitna:360-027.%7 400 Belfur:360-VS ,Ext a�!a9ri..,m°emrmm.w!x.n.0 urx+nn EIme:360-492- 9.Fxt400� Application for Determination of Water Adequacy Q p%3 Instructions RFC OZO�� 1. Complete Part 1. No determination can be made until Part 1 is fully completed. �0 2. Complete only the portion of Pert 2 applying to the type of water connection utilized. 3. Submit completed application,with any required attachments for review. 4. An approved building site plan must acecrnpagy this application. i Part 1: Applicant)Parcel Identification Name on Applicant: Jaron Roque Date: 11/19/2024 Mailing Address: 2370 NW Raleigh St Portland OR 97210 Phone: 5109327669 Parcel Number: 42209-54-00097 Divislon-block-lot: 17-97 Type of Water System Reason for Application PublIcACommunity Water System(2 or more © Building permit connections) ❑ Division of land: ❑ Individual water source(one connection), p of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spdng/sudace water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name ff you have more than one residence connected of water system below if applicable—no to this well,check the PublieCommun/ty Water signature required) System box. Signature Jaron Roque Part 2: Water Connection Information Email Address jaron.roque@gmail.com Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: LAKE CUSHMAN SYSTEM 5 Water Facility Inventory(WFI)Number. 035290 (wdte'none'for two-party) ❑ I am the manager of this water system.The water system has been approved foA w1ces.There are presently connection(s)in use.This will be the connection. i 1 am the manager of this system.This connection will be to upgrade or change the use of an existing connection on this system(i.e.: recreational to full time). Please indicate on the following line the nature of thischange: No the esbarmrk eesvke This water system is able and willing to provide water to this(these)connection(s)without exceeding the limits of the water system or any limits set by state and local mguletion. Print Name of Water System Manager. Phone 360-877-2728 Signature of Water System Manage!. -Ems' Date f This form may be scanned and available for public view at www.co.masomme.iia. r:\M Format prmkmg wave Ravish4 7=1 Individual Water Well ❑ Water well report(attached to application). Depth (t. i ❑ Well capacity Test(attached to application) gpm gpd. The well driller often performs well capacity tests at the time the well Is constructed. Results from these tests are noted on the water well report. Results from these tests will be accepted. If the water well report cannot be located by the applicant or If the water well report does not have a capacity test, a well capacity test,which provides stabilization of draw-down and recovery data, must be performed !, by a licensed contractor. ❑ Satisfactory bacteriological test(attach to application). Water Resource Inventory Area(WRIA) Development within which WRIA httpJ/ois.co.mason.m.us/olamim 14_15_16_22_ Water use or limitation recorded................................... N/A YesI Well Drilled ............................................................... Daft Individual Spring/Surface Water ❑ WDOE permit(attach to application) ' ❑ Method of disinfection ❑ 1 have reason to believe that this water source can provide at least 800 gallons per day;and/or provides water at a rate of 2 gallons per minute based on the following observations. Author of Statement Data Relationship to Applicant Part 3: Mason County Community Services Evaluation staff use only Satisfactory Determination: This determination does not address adequacy of the distribution system,guarantee an adequate supply or water indefinitely in the future,or guarantee compliance with all applicable WDOE we resource r one. F Recommended approval indicates requirements of Sanitary Code,The a,Chapter 6. Date W0 Adequacy for Building PormXs are satisfied. Additional Growth Management requlremy. CHeQ[e1ro O 36,70A RCW. - FNV�Na ❑ Unsatisfactory Determination: 'D�J NMF Apppeanrewatwildpply dcOnUtappesradequate to'reael the needs of Its Intended use for Me folwmng reason(s). Reviewer's Signatures: Environ. Health: Date This form may be scanned and available for public view at vninfif co.mason lys,pg. PW 2 oft WATER FACILITIES INVENTORY (WFI) dater: ' ( FORM updaee: ,v,2rmza iMAkErs rD�.k.ry o, Pdnetl ,2,72024 Health ONE FORM PER SYSTEM WFI printed For: On-Demand a.wA..�rur.,va Submission Reason: Pop/Conne Updat Update RETURN TO: Central Services-WFI, PO Box 47822, Olympia,WA,98504-7822 or email wfi@doh.wa.gov 1. SYSTEM ID NO. 2. SYSTEM NAME ]. COUNTY 4, Spi '.6..TYPE 03529 D LAKE CUSHMAN SYSTEM 5 MASON A Central 6.PRIMARY CONTACT NAME 6 MAILING ADDRESS 7.OWNER NAME 6 MAN1MO ADDRESS CHEVON A.BROWNELL LAKE CUSHMAN MAINTENANCE CO. PRESIDENT,JUNE 2023- 3740 N.LAKE CUSHMAN RD. ELIZABETH STEPHENS HOODSPORT,WA 98548 3740 N.LAKE CUSHMAN RD. HOODSPORT,WA 98548 #BEET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS ADDRESS > ]ITV STATE ZIP CITY STATE ZIP 9.24 Hi PRIMARY CONTACT INFORMATNON 10.OWNER CONTACT INFORMATION marry Contact Daytime Phone: (360)877-2728 Owner Daytime Phone. (360)877-9668 'nmary Contact MobilsiCell Phone: (912)227-6426 Owner Mobile/Cell Phone: mary Contact Evening Phone: (xxx}xxx-xxxx Owner Evening Plwna: Fax: F-mall'. Cxxxxxxxt-@AKECUSHMANMi Fax. E-mail. bxaaxxxxsiplakecushmanmc.com 1.SATELLITE MANAGEMENT AGENCY-SMA(cheek only ore) JK Not applicable(Skip to C12) 1] Overeat and Managed SMANAME. SMA Number Managed Only Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark ell 20 apply) Agricultural HospitallClinic w Residential Commercial I Business Industrial School Day Care Licensed Residential Facility Temporary Fans Worker Food Service Bond Permit ❑Lodging ❑Other(chumh.Ore Intel etc.). El 1 OW or more person event for 2 or more days per year Recreational I RV Park ].WATER 9 STEN OVINERSHIP(mark only one) C. 51ORAGECAPACITY(gallons) Association E]Cdunty Investor Special District rl City l Tom Federal �Pnvate pstale 5T9.30D -SEE NEXT PAGE FORA COMPLETE LIST OF SOURCES- WATER FACILITIES INVENTORY (WFI) FORM - Continued �EYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE F7, . CUSHMAN SYSTFMS MASON18 1T 18 19 20 21 22 23SOURCENAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCELOCATION T GTILT"6 NAME FOR SOURCE m 0 m D AND WELL TAG ID NUMBER. r m w K O y zx D m p m y O a 4y0 D y = Example: WELL#1 XY2456 v p' m r 0 z a F �! A A w m r m w m O T 0 IF SOURCE IS PURCHASED OR INTERTIE w z s D ; SI m 3 F z w m w z O 3 INTERTIED, SYSTEM F n a p m r D D i O m m i D D i y z 0 =D 0 3 = LIST SELLER'S NAME ID m m x z a: a O ! O�O x 'gym yO m s .'g EiampN: SEATTLE NUMBER O o 0 o o A P < m y D A m s 2 2 S A .w 501 WELL#3AH136n D-5SMp % X Y % 35 165 NW HE 29 23N 04W 902 WELL#5AHS878D-14Pa* % X Y X 55 118 SW NE 05 22N O4W 904 WELL IS AHM79 D-14 Pah % % V X 93 165 SW NE 05 22N OWW SOS WELL#T M8675D 1a1 Hole GC X X Y X 40 60 SESW 04 22N 04W SOS WELL 111 AHM76 D-T 2n#Hok GC X X Y X 94 98 NE NW 09 22N 04W 907 WELL#40-9 PaA % X Y % 18 SO SW HE 16 22N O4W SOS SOt WELLkt 93$21VAAKE COSH#1 % X V % 145 NE NE 29 23N O4W SOB SDY WELL#903521YI ECUSH#1 X X Y % 192 110 NW NE 29 23N O4W izc. 96' I IS I.. T� .L1 r, a. S C a � T m 7clil i Z A 1 ��,ppl y — m 6 m m m ''o O L" S N4 VI 1}y iC N `n m � � O 1 y