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Home My WebLink AboutWAT2025-00071 - WAT Application - 4/1/2025 . WAT aso� -ODOR MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 415 N 6th Street, Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ Elma:(360)482-5269 ext 400 FAX(360)427-7787 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: ,,4 Qpj- p Date: .3-/7 -aeo2rj Mailing Address: 00 Nk/"/%Ssi o•O Cj1°'�K Phone: 340 y0( '7l is Parcel Number: 3a./4 L/ - 50- 0004.S Type of Water System Reason for Application BO4 17 VI Public/Community Water System (2 or more t Building permit B�o�2.0 ' connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ Other(explain) 0 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 � Name of Water System: f^ /4't-g- a o1,1 el L'cC K Water Facility Inventory(WFI)Number: 2-3 CC (write"none"for two-party) i rrt I am the manager of this wa er system.The water system has been approved for G 5 services. / There are presently cr '4 connection(s) in use.This will be the 9 p;Lconnection. 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. Signature of Water System Manager Date t/ i/2_ -c This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well O Water well report (attached to application). Depth ft. O 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. O Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14= 151-1 161 122= Water use or limitation recorded N/A 0 ,Yes I I Well Drilled Date Individual Spring/Surface Water O WDOE permit (attach to application) O Method of disinfection O 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-Deterrninatibnrof Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 36.70A RCW. .a: � ., Unsatisfactory Determination: '`9 ,� � Applicant's water upply does not appear adequate to meet the needs of its intended use for ' llowif�gP2 reason(s). 47), Q?G ® Reviewer's Signatures: Environ. Health: Date `1 3D . CSD Director: Date 2 of 2 WATER FACILITIES INVENTORY (WFI) Quarter: 2 Updated: 09/27/2022 950 Watteington State Department of FORM Health Printed: 5/1/2025 ONE FORM PER SYSTEM WFI Printed For On-Demand Umi<+on ML'naironrnrnloi Ilr:drh Office of brirrking Woler Submission Reason: No Change ??�� RETURN TO: Central Services -WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@doh.wa.gov 1. ST�TEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 23294 W EMERALD LAKE MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILlt4G ADDRESS ANDREW J. NOBLE[H2O MGMT SERVICES] EMERALD LAKE COMMUNITY CLUB OWNERS REP H2O MANAGEMENT SERVICES INC STEPHEN KOVACH PO BOX 2026 140 E EMERALD LK DR E SHELTON,WA 98584-5034 GRAPEVIEW,WA 98546 IMOIR ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE 4TTN ATTN 4DDRESS ADDRESS SIT, STATE ZIP CITY STATE ZIP 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)427-0654 Owner Daytime Phone: (360)427-9074 Primary Contact Mobile/Cell Phone: (360)463-6189 Owner Mobile/Cell Phone: Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone: (xxx)-xxx-xxxx Fax: E-mail: hxxxxxxxs@gmail.com Fax: IE-mail: 1.SATELLITE MANAGEMENT AGENCY-SMA(check only one) ❑ Not applicable(Skip to#12) • Owned and Managed SMA NAME: H2O Management Services Inc. SMA Number:140 114 Managed Only ▪ Owned Only . WATER SYSTEM CHARACTERISTICS(mark all that a.. . ❑Agricultural ❑ Hospital/Clinic IK Residential Commercial/Business El Industrial 0 School • Day Care 0 Licensed Residential Facility 0 Temporary Farm Worker ▪ Food Service/Food Permit 0 Lodging D Other(church,fire station,etc.): • 1,000 or more person event for 2 or more days per year )4 Recreational/RV Park 1 'WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) ❑Association 0 County ❑Investor 0 Special District City/Town 0 Federal iiii Private 0 State 105,000 16 17 18 19 20 21 22 23 24 . 1/15: SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION Z m o LIST UTILITY'S NAME FOR SOURCE z y m O = D m AND WELL TAG ID NUMBER. i �_ pp y D - N 'n z = r D �O y0 A --I oc Example: WELL#1 XYZ456 v m D ?I v m m r c o m Imtnn 3 O —1 O F. D T m o 0 -i to IF SOURCE IS PURCHASED OR INTERTIE I- r. rn Gzi z D m D 0 5:3 D o(no rn z �F� o p E y 3 m c 3 SELLER'S SYSTEM m m m m m D D m = m z m r 0 '1 -D—i z x m S O "., ao Cn Z F. LIST SELLER'S NAME ID m r r r z r r m m z m z D z m z 0 0 0 c m mm tz 0 m = m Example: SEATTLE NUMBER r o o O o o M XI .< xl -4 r •< 0 rn z z z S z -a z m y z m z m SO1 WELL#1 WW ABR516 X X Y X 97 60 NE NW 24 21N 03W SO2 InAct 04/16/1991 WELL#2 ABR517 X X N X X 114 60 NE NW 24 21N 03W S03 WELL#3 WW ACD400 X X Y, X 109 60 NW NW 24 21N 03W SO4 WF(S01,603) X X Y X 97 120 NE NW 24 21N 03W n....... WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 23294 W EMERALD LAKE 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?) 94 155 A. Full Time Single Family Residences(Occupied 180 days or more per year) 94 B. Part Time Single Family Residences(Occupied less than 180 days per year) 0 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) 45 45 0 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 0 0 0 28. TOTAL SERVICE CONNECTIONS 139 155 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 249 POPULATION JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many part-time residents are present each month? 30 30 30 48 48 48 48 48 48 48 30 30 B. How many days per month are they present? 4 4 4 8 8 14 14 14 8 8 4 4 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 300 280 600 600 900 900 1200 1800 1200 300 300 300 or customers have access to the water system each month? B. How many days per month is water accessible to the public? 30 28 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 employees are present each month that are NOT already included in the residential population? B. How many days per month are they present? 33. ROUTINE COLIFORM SCHEDULE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 1 1 1 1 1 1 1 1 1 1 1 1 34. NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY 3 YEARS (One Sample per source by time period) 35. Reason for Submitting WFI: ❑Update-Change 0 Update-No Change ❑Inactivate ❑Re-Activate 0 Name Change ❑New System ❑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: