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Home My WebLink AboutWAT2025-00048 - WAT Application - 3/10/2025 FAT ADAI - 000 415 N.6'b Sheet Q01MASON COUNTY Skfty WA98584 COMMUNITY SERVICES Shdl 360427-9670,Pan.400 eelfsh:360-275- 467,ExL 400 emiervvv��ry rmn,,.m. iwMen.mmm�mrve®nn Elme:360�482-5269,Ext 400 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/ 'A P rcel Identification j i Name on Applicant: DYYI fYY'JG Date: .3'10 -� Mailing Address: _1,0 f6X ",El r C IA)A CIIAS141 Phone: 3U0. 470• B ia5 Parcel Number: 32104-56-00039 Type of Water System Reason for Application Ed Public/Community Water System(2 or more Building permit�V 1 d�0;5^00, 40 connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface 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 wefl, check the Public/Community 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(WFI)Number: 01050 B (write"none"for two-party) 5( 1 am the manager of this water system.The water system has been approved for Safi services.There are presently 534 connection(s)in use.This will be the 535 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 limits of the water system or any limits set by state and local regulation. Print Name of Water System Manager Brandy Milroy Phone 360-877-5249 Signature of Water System Manager A%., L �&4 Date 04116/2024 "ter This form may be scanned and available for public view at www.co.mason.wa.us. J;E Fw \Drv*mg Water Revisal W27=1 Group B Water Systems ❑ 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 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 within last year(attach to application). 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 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 ad of water indefinitely in the future,or guarantee compliance with all applicable WDOE water ms ations. Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.W-Det n of Adequacy for Building Permits are satisfied. Additional Growth Management reVirements may at t@r ElUnsatisfactory Determination: ASO*0Opgp�1s Applicants water supply does not appear adequate to meet the needs of its intended use fdrfo ilow �n reason(s). pN4i 4 FNr,. �///�/, Reviewer's Signatures: Environ. Health: all,--- l,--- Date / Gae This form may be scanned and available for public view at www.masoncountvwa.aov Page 2 of WATER FACILITIES INVENTORY (WFI) Upload: 0110812025 025 Ilma yFin FORM Health Printed For: On-Demand "Op Health FORM PER SYSTEM WFI Printed For: On-Demantl "m^! "xWµ Submission Reason: Pop/Connect Update RETURN TO: Central Services-WFI, PO Box 47822,Olympia,WA, 98504-7822 or email wfi@doh.wa.gov I. SYSTEM iD NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 01050B ALDERBROOK WATER CO MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS T.OWNER NAME MAILING ADDRESS BRANDY A. MILROY[WATER RESOURCE MANAG] MASON COUNTY PUDI WATER RESOURCE 21971 N HWY 101 BRANDY A.MILROY SHELTON,WA 985M 21971 N HWY 101 SHELTON,WA 98594 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP 9.24 HOUR PRIMARYCONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary bar. OaNime Phone: (360)877-5249 Owner Daytime Phone: (360)8]J-5249 x268 Primary Contact MothlelCell Phone: (360)490-2459 Owner MobilelCell Phone: (360)490-2459 Primary Contact Evening Phone: (xxx}xxx-xxxx Owner Evening Phone: (xxx}xxx-renx Fax'. E-mail hathinm@nrason-pudt.org Fax: (360)8]]5339 E-mail: bxxxxxm@mason-pudt.org 1.SATELLITE MANAGEMENT AGENCY-SMA(check only one) Not applicable(Skip to#12) X Owned and Managed SMA NAME: MASON COUNTY PUD 1 SMA Number:111 Managed Only Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all Not apply) Agncul uhal Hospite/Clinic X Residential �[Commercial l Business ❑Industrial ❑ School Day Care ❑Licensed Residential Facility ❑Temporary Farm Worker Food Servicell'ood Permit Lodging 1K Other(church,fire station,etc.): 1,000 or more person event for 2 or more days per year p Recreational I RV Park .WATER SYSTEM OWNERSIP(mark only one 4. STORAGE CAPACITY(gallons) Association Counry ci Investor Special District City l Town Federal Private Slate 300,000 is 16 17 16 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION as c in 22 LIST UTILR S NAME FOR SOURCE E zi c $ w FF S v re AND WELL TAG IO NUMBER. g c D A in 2 a y Cx, w p 2 m n c n0 AO Example: WELLA11rYib456 S m 2 p m A w m ra 8 y 8 = rN to H i O z as IF SCIIRCE IS PURCHASED OR INTERTIE rr r w O T F O D H O 2 O O O �� 3� m c F 3 INTERTIED, SYSTEM F 'r f i T — m m A m i 2y A m i 0 0 0 m in 2 O m 2 In LIST SELLER is 'S NAME IO m C Example: SEATTLE NUMBER r 0 c O o 6 A .'a < A H r < O m 2 z z 5 A �z w z A a m SOt WELL#t BBS716 % X Y X 292 1W SWSW I Nt 121N 03W S02 WELL#2 BBS717 1xi X V X 600 140 NW SE W 21N 03W S03 WELLIKIBBS716 X x V X 262 700 NENW 09 21N 03W WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 01050E ALDERBROOKWATERCO MASON A Comm DOH USE ONLY! OH USE ONLY ACTIVE CALCULATED AppROVEO SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(How many of the following do you haysi) 527 636 A. Full Time Single Family Residences(Occupied 180 days or more per year) 490 B. Part Time Single Family Residences Cocupied less than 180 days per year) 37 26. MULTI-FAMILY RESIDENTIAL BUILDINGS(H.many of the following de you bevel) A. Apartment Buildings,condos,duplexes,barracks,dorms 0 B. Full Time Residential units in the Apartments,Condos,Duplexes,Dorms that are occupied more than 100 daystyear 0 C. Pan Time Residential Units In the ApanmenS,Condos,Duplexes.Dorms that are occupied less than 100 daysi 0 27. NONRESIDENTAL CONNECTIONS IN.marry of the following do you Im i( A.Recreational Services and/or Transient Accommodations(Campsites,RV sites,hotelfmotelfovemighl units) 0 0 0 B. Institutional,COmmercaaVBuslness,School,Day Care,Industrial Services,etc. 20 20 0 28. TOTAL SERVICE CONNECTIONS 547 636 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 1366 30. PART-TIME RESIDENTIAL POPULATION JAN FED MAR APR I MAY JUN JUL AUG SEP OCT NOV DEC A. How many pan-time residents are present each month? 10 10 10 30 48 48 48 48 30 10 10 10 B. How many days per month are they present? e 8 8 12 12 12 12 12 12 8 8 8 31. TEMPORARYSTRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many total visitors,attendees,travelers,campers,patients 1000 5000 5000 10000 15000 22100 22100 22100 15000 5000 5000 10000 or customers have access to the water system each months B. How many days per month is water accessible to the pudic? 30 30 30 30 30 30 30 3C 30 30 30 30 32. REGULAR NONRESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. If you have schools,daydares,or businesses connected to your water system,how many students,daycare children surfer 20 20 20 20 30 30 30 30 20 20 20 20 employees are present each month that are NOT already included in the residential population? B. How many days Fair month are May present? 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 NOV DEC 2 2 2 2 2 2 2 2 2 2 2 2 U. NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY3YFAR5 (One Sample per source by It pariadl 35. Reason for Submitting Wli ❑Update-ChanBs ❑ Update-No Change ❑Inactivate ❑Re-Activate [I Name Change ❑New System ❑Other X. I certify that the Information atsted on this WFI form Is correct to the best of my knowledge. SIGNATURE: DATE: PRINT NAME: TITLE: