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Home My WebLink AboutWAT Application MASON COUNTY DEPARTMENT OF HEALTH SERVICESRECEIVED Eovironmental Health it it t I) 2M02 Personal Health Sn 426 W! CEDAR BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 BELFAIR(360)2754467&4469 Application for Determination of Adequacy Instructions _ i Complete Poi'I. No determination can be made until Part I is fully completed. Complete only the portion of Part 2 applying to the type of water system utilized 3. Submit completed application,with attachments to the health department for review PART 1: Applicant/Parcel Identification Name of Applicant Ka ikLdQ LkLisi0hDate Mailing Address o Telephone a 5 3 -32 S-r- 333 3 Assessor's Parcel Number I -(. 3 3 1 - S 1 - bo 6 6 A of Water System Check One): Reason orA lfcadon Check One): PublidCommunity,Water System(2 or Building permit ronoectiais) ❑ Land use application,if so.. ❑ Individual water source(ane coMectton),if W.. ❑ Division of land ❑ Well #of Parcels? ❑ Spring/surface water SPH9_- ❑ Other(explain) ❑ Boundary line adjustment ❑ Other(expla!a) PART 2: Water System Information Complete the Vetion appropriate for the type of water system being evaluated for adequacy: Public Water S stem Name of Water System aact Co Ur m--t;7- Water Facility Inventory(WFI)Number: a The water purveyor has filed a letter grunting blanket hookups to this water system. ❑ I ern the manager of this water system. The water system has been approved for services. There are presently connections m use. This will be the connection. a water system is able and willing to ptevtdee water to this(these)connections wr out t`�ding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date H IWDATA URCHIVO WA2 D3.WP tlpdale:March 22.19 W - 7 Individual Water Well ❑ Water well report(attach to application) Depth ft. ❑ Well capacity test(attach to application) giant gpd Well capacity tests are of7en performed by the well driller at the time the well is constructed Test results am these tern are noted on the water well report Results from these tests will be accepted Ijthe water well report cannot be located by the applicant or ijthe water well report does not have a capacity test, a well cap achy test, which provides stabilization ajdraw-down and recovery data, mus t be performed by a licensed contractor. ❑ Satisfactory bacteriological test(auach W application) Individual SpringlSwface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ I have reason to believe that this water source can provide at least$00 gallons per day and/or provides water at a rate of 2 gallons per mbrute based on the following obselvatrons. AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT In addition to providing the above statement, the aappplicant will need to arrange an on-.site bapection by the health department prior to determination ofaaequaey Departmental use only. Do not write below this line. PART 3: Health Department Evaluation (staff use only) ❑ -SATISFACTORY DECEI MINATION: Applicant's water supply appears adequate to " meet the needs of its intended use. Yhisdetcindnationdoesrui address adequacy of the dish ibution system, guarantee an adequate supply of water indefinitely into the future, or guarantee compliance: with all applicable IYDOE water resource regulations. ❑ UNSATISFACTORY DETERMINATION: Applicant's water supply does not.appear adequate to meet the needs of its intended use for the following reason(s): REVIEWER'S SIGNATURE DATE HIWDATAURCI ZIWATMD.t WP Update:March 22,IM 1NKUJ5—N24 TEL 1`10:360 664-9058 #553 P02 H t QW 3 �3 ' �� a TE OE WASHINGTON MENT OF HEALTH (� )KINKING WATER OPERATIONS O(ympi+, Washington 98504-7823 • (360) 66"768 F May 4, 1995 ny 1 act: Lake Cushman Maintenance Company, ID #'s 035290, 03530L, 03527Y, 03528F, Mason County; Approved Number of Connections evleweci the information provided by your engineer, Mr. Pat Byrne, P.E., for each of the four subject water systems owned and managed by the Lake Cushman Maintenance Company. As you are aware, Mr. Byrne has provided this Information on system capacities and historical water usage in order to determine an approved number of connections for each Lake Cushman water system. It was also hoped that this analysis might provide justification for lifting the existing moratorium on building permits. Following our review of the information, approved numbers of connections have been established as follows: WATER SYSTEM PWS ID# APPROVED EXISTING CONNECTIONS CONNECTIONS Division #5 W.S. 035290 701 738 (Group A) Division #10 W.S. 03530L 12 229 (Group BI Division #1 W.S. 03527Y 257 148 (Group C) Division #3 W.S. 03528F 361 320 (Group D) Background Lake Cushman subdivision is served by four water systems. These water systems were reviewed by Washington Department of Health in June 1995,and their status was summarized as follows: Designation Divisions Status Lk.Cushman DivisionI GroupC I Adequ Division 3 Group D 2,3,4 Ad,. Division Group 5.6,7,8,9, Adeq ,.�x911.be dedaredvery,._ ' J,I4, 15,17.18.19 40, tank has been arti l ,utdT will intent i:-e nd rime Division 10 Group 10,12,16 A ent anisonly 111mr,W tank will be constructed n can n,allmed,although RV connections sidmfial...ctions In March 1996,Washington Department of Health reassessed of „ systems after it came to their attention that Lake Cushman Association did not have suffici'� ,rights.; #the four water systems. The agency determined that since they had approved DOH.Divisio and 10 as adequate,they would honor their committment to allow additional connections to those water s. The agency determined that they would accept the Cushman engineer's certification that the storage adequate, but would designate the system "adequate at capacity"meaning no additional connections to system would be approved. Policy The Mason County Board?of.Health hereby:authorizes and directs Mason County Department of Health Services to designate the water system identified asp:DORDivision 10 as "adequate" for purposes of issuance of building permits provided the following conditions are met: 1. i 'he new storage tank most be on-line and the water system must be in compliance with WAC 246- C 291 in all areas except water rights Each applicant must sign and record a statement holding the county harmless in case their access to water is limited in the future due to a court decision related to the allocation of water rights. The local fire district must provide a written statement for each connection,or a single statement for . all of DOH Division 10,verifying that"fire flow"issues have been addressed. 4. The Lake Cushman Association must sign a written statement of approval for each connection or a sign statement covering all of DOH Division 10.