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Home My WebLink AboutWAT2025-00049 - WAT Application - 2/16/2025 5 , MASON COUNTY �WAT EC2oZ E I V E- DOooq� ,. jk COMMUNITY DEVELOPM EN , H CQY Permit Assistance Center,Building,Planning ,I A�j O 2025 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 Elma: (36Q��$77_ yY1y1 ff�1 2-5269 e 400 Street FAX(360)427-7787 vv 11GQer 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 on Applicant: 'K+�:,,,l,;'\ 0 i scol Date: / / i 1:;i /7.-c->" 'Z-c Mailing Address: t -c 1 e<<_ k R+l e 1viPhone: �- -- -Z ---3i I Z-_ Parcel Number: 3 i `2-77 - c1:3 — Off,01 7 0 I ^67 l 5-0 6. PGfi6trfra e. xType of Water System Reason for Application Public/Community Water System (2 or more Building permit connections) 0 Division of land: O Individual water source (one connection), #of Parcels? SPL O Well ❑ Boundary line adjustment ❑ Spring/surface water 0 Other(explain) O 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 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 Wr , , Name of Water System: Lcd 1� L i v �-+rt /C-- c` f 5y wA Water Facility Inventory(WFI) Number: 4 Li I coT (write"none" for two-party) X I am the manager of this ' ter system. The water system has been a proved for/3 T2services. -, There are presently� SL—connection(s)in use. This will be the 3connection. 0 I 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. 20 > � Date- 2 '/lv "Z-0Z5_ Signature of Water System Manager �` This form may be scanned and available for public view at _ ;,.-,:.co.masoo.wa.us• 11FH Form; Drinkine\Vatcr Revised 1/25/2018 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) 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 within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) O Method of disinfection 0 I 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 supply of water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations. Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Determination of - Adequacy for Building Permits are satisfied. Additional Growth Management requikvents may, / . Chapter 36.70A RCW. °tiCOU 4I6, Unsatisfactory Determination: 1 Applicant's water supply does not appear adequate to meet the needs of its intended use for he IQ O�s reason(s). ✓.Q '�FiylN Reviewer's Signatures: 1 6 (7dzy Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER FACILITIES INVENTORY (WFI) Quarter: 1 Updated: 12/18/2023 Washington State Department of FORM /� ��Health ONE FORM PER SYSTEM Printed: 4116/2025 WFI Printed For: On-Demand lhvi•ion of CuvireomenWI f icnith Office of ISrinkiug Wat« Submission Reason: Contact 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 3. COUNTY 4. GROUP 5. TYPE 44150 T LAKE LIMERICK WATER MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS , CHRISTOPHER M. MCMULLEN [OPERATOR] LAKE LIMERICK COUNTRY CLUB INC GENERAL MANAGER 790 E ST ANDREWS DR CHRISTOPHER M. MCMULLEN SHELTON,WA 98584 790 EAST ST.ANDREWS DRIVE SHELTON,WA 98584 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 PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)426-4563 Owner Daytime Phone: (360)426-3581 Primary Contact Mobile/Cell Phone: (360)580-5271 Owner Mobile/Cell Phone: Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone: Fax: E-mail: wxxxr@lakelimerick.com Fax: IE-mail: wxxxr@lakelimerick.com 11.SATELLITE MANAGEMENT AGENCY-SMA(check only one) X Not applicable(Skip to#12) • Owned and Managed SMA NAME: SMA Number: D Managed Only n Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) n Agricultural n Hospital/Clinic X Residential ▪ Commercial/Business 0 Industrial El School • Day Care El Licensed Residential Facility El Temporary Farm Worker X Food Service/Food Permit 0r Lodging X Other(church,fire station,etc.): NI 1,000 or more person event for 2 or more days per year 151 Recreational/RV Park '13.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) ❑Association 0 County ❑Investor 0 Special District ❑City/Town 0 Federal Private 0 State 320,000 -SEE NEXT PAGE FOR A COMPLETE LIST OF SOURCES - WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 44150 T LAKE LIMERICK WATER MASON A Comm 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION cn T o m X T. m D LIST UTILITY'S NAME FOR SOURCE m Z Z N v cn AND WELL TAG ID NUMBER. Z z c -< c% m 7�� m A m D O _ -_-i °c Example: WELL#1 XYZ456 * A cil m WI A 71 m o 3 m 0 T 0 D `r 71 m A Z —I 19 IF SOURCE IS PURCHASED OR INTERTIE r' m Z Z D m 0 3 D A m E xi a '{ z-i 3 m c < z INTERTIED, SYSTEM rn m m rn D D m x m Z Z A 0 1 1 Z x m c rp —I co 0 Z a LIST SELLER'S NAME ID m m Example: SEATTLE NUMBER r 0 0 6i 0 0 A A - A - r -< o m Z Z Z . z -I Z m cn Z A V m SO2 WELL#2 AHA978 X X Y X 103 200 NE NW 27 21N 03W S03 WELL#3A AHA976 X X Y X 110 144 NW SW 27 21N 03W SO4 WELL#4 AHA973 X X Y X 92 74 SE SW 22 21N 03W S05 WELL#1 AHA974 X X Y X 89 49 NE NE 27 21N 03W SO6 WELL#3B AHA975 X X Y X 167 194 SW SW 27 21N 03W S07 WELL#5 AHA977 X X Y X 110 35 NW SW 27 21N 03W S08 WELL#6 ALH995 X X Y X 429 248 SE SW 27 21N 03W n WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 44150 T LAKE LIMERICK WATER MASON A Comm DOH USE ONLY!DOH USE ONLY! ACTIVE CALCULATED APPROVED SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 844 Unspecified A. Full Time Single Family Residences(Occupied 180 days or more per year) 773 B. Part Time Single Family Residences(Occupied less than 180 days per year) 71 26. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have?) A. Apartment Buildings,condos.duplexes,barracks,dorms 0 B. Full Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied more than 180 days/year 0 C. Part Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied less than 180 days/year 0 27. NON-RESIDENTIAL CONNECTIONS(How many of the following do you have?) A.Recreational Services and/or Transient Accommodations(Campsites,RV sites,hotel/motel/overnight units) 354 354 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 3 3 28. TOTAL SERVICE CONNECTIONS 1201 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 1920 30. PART-TIME RESIDENTIAL POPULATION JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many part-time residents are present each month? 48 96 142 142 142 47 47 B. How many days per month are they present? 30 30 30 30 30 30 30 31. TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many total visitors,attendees,travelers,campers,patients 1200 1200 1200 1200 1600 1600 1600 1600 1200 1200 1200 1200 or customers have access 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 32. REGULAR NON-RESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. If you have schools,daycares,or businesses connected to your water system,how many students,daycare children and/or 21 28 29 30 34 33 34 29 29 26 27 22 employees are present each month that are NOT already included in the residential population? B. How many days per month are they 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 34. NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY 3 YEARS (One Sample per source by time period) 35. Reason for Submitting WFI: ❑Update-Change ❑ Update-No Change ❑Inactivate ❑Re-Activate El Name Change ❑New System 0 Other 36. I certify that the information stated on this WFI form is correct to the best of my knowledge. SIGNATURE: DATE: PRINT NAME: TITLE: 0