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Home My WebLink AboutWAT2025-00028 - WAT Application - 3/24/2025 ENVIRONMENTAL HEALTH MASON COUNTY `' 415 N.hon,W 5neet Shelton,WA 96584 Public Health & Human Services FEB It 25,bixfton:3fio-427-9670,E..400 HeHav: 60-275-0 67,ExL 400 �ru Alder Street Application for Determination of Water Adequacy Instructions 1. Complete Part 1. No determination can be made until Part 1 is fully completed. 2- Complete only the portion of Part 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 accompany this application. Part 1: Applicant/ Parcel Identification Name of Applicant:OLIO^^,—,� f' OIYC-5 qLL L Data Mailing Address: 1/905-1 JelyiJ1gC k)c 50 Phone: 253 W' M - 9.22( 1106 .26 f'1WG3 Parcel Number: 32104-54-00120 5�P A- Q 810 F Type of Water System Reason for Application 11' PublidCommunity Water System(2 or more V( Building permit FILM GrU5—Cc I V� connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spdng/sudace water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name If you have more than one residence connected of water system below if applicable—no to this well,check the PublidCommunity Water signature required) System box. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: Alderbrook Water Facility Inventory(WR) Number: 01050 B (write"none'for two-parry) 91' 1 am the manager of this water system.The water system has been approved for 636 services.There are presently s4i connection(s)in use.This will be the 542 connection. ❑ 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 this change: This water system is able and willing to provide water to this(these)connection(s)without exceeding the limbs of the water system or any limits set by state and local regulation. Print Name of Water System Manager Brandy Milroy Phone 360-677-5249 Signature of Water System Manager_(_,;�_: ,i Date 12/04/2024 This form may be scanned and available for public view at www.masonmuntywa.aov J:1EH Foams\D�g Water RMv 05!1)81024 Page I M 2 Group S B Water stems Y ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) opm opd. The well driller often performs well capacity tests at the time the well is constructed. Resuhs 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 within last year(attach to application). Individual SpringfSurface 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 Date 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 s pty of water indefinitely in the future,or guarantee compliance with all applicable WDOE water resour one. Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Deter Qf Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. ply 36.70A RCW. F Unsatisfactory Determination: *4xO Applicant's water supply does not appear adequate to meet me needs of its intended use for Hold reason(s). FNy�, 1p1 O N Reviewer's Signatures: /..., C �FNT'Q Environ. Health: Dale 1)L/L/ � This form may be scanned and available for public view at www.masoncountvwa.eov Page 2 of 2 WATER FACILITIES INVENTORY (WFI) pVane': 1 Updatetl: 01/082025 ��yyy FORM Pri025 lf*Health Printed r On-Demand ONE FORM PER SYSTEM wFI Printetl For: on-Demantl 9' 1 w,e,v..,w Submission Reason: Pop/CoUpdatepdatennect U RETURN TO: Central Services-WFI, PO Box 47822,Olympia,WA,98504-7822 or email wri@doh.wa.gov 1. SYSTEM ID NO. 2. SYSTEM NAME a. COUNTY 4. GROUP S. TYPE 01050E ALDERBROOI(WATER CO MASON A CWmm O.PRIMARY CONTACT NAME B MAILING ADDRESS 7.OWNER NAME A MAILING ADDRESS BRANDY A.MILROY(WATER RESOURCE MANAGI MASON COUNTY PUD 1 WATER RESOURCE 21971 N HWY 101 BRANDY A MILROY SHELTON,WA 98594 21971 N HWY 101 SHELTON,WA 98584 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE 4TTN ATTN ADDRESS ADDRESS _IN STATE ZIP CITY STATE ZIP 0.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Drimary Contact Daytime Phone: (360)8]]-5249 Owner Daytime Phone: (360)877-5249 x268 'dmary Contact MobilalCell Phone: (360)490-2459 Owner Mobile/Cell Phone: (360)490-2459 ? mary Contact Evening Phone: (xxx}xxx-xxxx Owner Evening Phone'. (xxx}xxx-xxxx a.. E-mail. bxxxxxm@mason-pull org Fax (360)8]]-5339 E-mail: bxxxxxm@mason-pudi org 1.SATELLITE MANAGEMENT AGENCY-SAIL(Whack only ono) Not applicable(Skip to#12) Owned and Managed SMA NAME: MASON COUNTY PUD t SW Number 111 Managed Only Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark BN tlml apply) Agricultural HospitallCllnic Residential Commercial l Business lodustdal School Day Care ❑ Licensed Residen0at Facility ❑Temporary Farm Worker Food SarvicelFaotl Permit ]K Lotl91n9 Other(rhumb,fire statical etc.): El 1,000 or more person event for 2 or more days per year 10 Recreational)RV Park - .WATER SYSTEM OWNERSHIP(mark Will oil MOE CAPACITY(gallons) �Association County o Investor Special District City l Town Fetleral Private State 300,000 15 16 17 10 19 M 21 22 23 u SOURCENAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTN SOURCELOCATION na LIST UTILRYS NAME FOR SOURCE F C w al ax A D In AND WELL TAG ID NUMBER. P 4 c �_ c no my n — O r — al T $ m a D m at Z m m I C O c O aExample: WELL MI%YZ658 m >) p �n O ? re 'A m re P T z -Di �z Pc z O z IF SOURCE IS PURCHASED OR INTERTE r ve IT F w L=i : j O : m m D D z y O z� O ; 2 INTERTIED, SYSTEM f T T p p y D r y O z y c y m w Q LIST SELLER'S NAME ID In z m I m m a, on y n m m 0 0 0 c m m m p�z O m S Example: 9EATTLE NUMBER r a o O o a a a A < O z z z S z •x M x A m SOf WELL#1 BBS716 X X Y X 292 150 SW SW 04 21N 03W 902 WFLL#205S]1] % X Y X 600 140 Net SE W 21N 03W S03 WELL p3 fiB5718 % X Y X ]00 NE NW 09 21N 03W WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2 SYSTEM NAME 3. COUNTY 0. GROUP S. TYPE 01050E ALDERBROOK WATER CO MASON A Comm H USE ONLY! OH USE ONLY ACTIVE CALCULATED APPROVED SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(Now many of Me fallowinp its you have?) 527 636 A. Full Time Single Family Residences(Occupied 160 days or more per year) 490 B. Pad Time Single Family Residences(Occupied less than 180 days per year) 32 ML MML MILY RESNIENT BUILDINGS(Hear many Wf 100& nS tlo you hawk A. Apartment Buildings,condo, duplexes,barracks.dorms 0 B. Full Time Residential Units In the Apartments.Condos,Duplexes,Dorms that are Occupied more Ilan 180 dayslyear 0 C. Pad Time Residential Units in the Apartments,Condos,Duplexes.Dorms Mat am Occupied less than lK dayalymr 0 Zy. NON#ESDENIML CONNECTIONS(How array of Um followlfp b you Never A.Recreational Serviws and/or Transient Accommodations(Campsites,RV sites,holellmotel/ovemight units) p 0 p B. Institutional.COmmemialiBusiness,School,Day Care,Industrial Serviws,etc 20 20 0 18. TOTAL SERVICE CONNECTIONS 547 1 636 9A NWTME RESIDENTIL POPULATION A. How many residents are served by this system 180 or more days per yea? 1368 $0. PART-ME RESIDENTIAL POPULATION JAN FEB I MAR APR MAY JUN JUL AUG SEP OCT NOV ;10 A. HOW many pan-time residents are pre5enteace month? 10 10 10 30 48 48 48 46 30 10 10 B. How many tlays par month ere they present? 8 8 8 12 12 12 12 12 12 8 8 at. T91PDRARYy TRAmeE USERS JAW FEB MAR APR MAY JUN JUL AUG SEP OCT NW A. How many total viaaas aaendees,traveleq carp,ma patients 1000 5000 5000 10000 15000 22100 22100 22100 15000 5000 5000 OI OuatOlnem have aga d,to the water system each month? B. How many days per month is water accessible to the public? 30 30 30 30 30 30 30 30 30 30 30 30 al 33. REGULAR NONRESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP MT NOW DEC A. If you have achcols,cafeteria,or bualneaus connected to your water system,how many students,daycare children andlor empbyeaa am prelim each month that ate NOT already included in 20 20 20 20 30 30 30 30 20 20 20 20 Me residential population? B. How many days per month am they preunt? 30 30 30 30 30 30 30 30 30 30 30 30 33. ROUTINE COLIFORM SCHEDULE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT MW DEC 2 2 2 2 2 2 2 2 2 2 2 2 34. NR TE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY3YFiLRB (One Sample per source by time period) 35. Reason for SubmlOng WFI: ❑Update-Change ❑ Update-NO Change ❑Inactivate ❑Re-Activate El Name Change El New System ❑Other 30. 1 Partly that the Information Mated on Has WFl fora Is contract to the best of my knowledge. SIGNATURE: DATE: PRINT NAME: TITLE.