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Home My WebLink AboutWAT2025-00063 - WAT Application - 8/19/2025 WAT 20 - 000(03 • 415 N.6'h Street MASON COUNTY Shelton,WA 98584 P' COMMUNITY SERVICES Shelton:360427-9670,Ext.400 Belli&360-275-4467,Ext.400 \.,v Building.Planning,Envkoomental Health,Community Healih Elma: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/ Parcel Identification �r Name on Applicant: fA (NV' Y s 0r) Date: I I g Mailing Address: t 02O 06 LJtr'soh 13( v d Phone: 3 1,o .5<t 3 c 3 Z 3 Parcel Number: 12 5.3 .. J ( '" O Ci 13 3 Type of Water System Reason for Application NPublic/Community Water System (2 or more Building permit a1...1)9.0 1_ c0367 connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water 0 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 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: Beards Cove Water Facility Inventory(WFI)Number: 05100E (write"none"for two-party) ❑ I am the manager of this water system.The water system has been approved for services. There are presently connection(s)in use.This will be the connection. ® 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: park model tiny home placement on lot. This water system is able and willing to provide water to this (these)connection(s)without exceeding the limits of the water system or an li 's s ate and local regulation. Signature of Water System Manager/5e - 1/4_— Date 6/6//f�02. This form may be scanned and available for public view at www.co.mason.wa.us. J:\EN Forms\Drinking Water Revised 4/4/2018 Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) qpm 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(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14_15 16 22 Water use or limitation recorded N/A Yes Well Drilled Date Individual Spring/Surface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection ❑ 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 • • I 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 6.68.040-14etermination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements.r ay apply. Chapter 36.70A RCW. Unsatisfactory Determination: 4`' �, Applicant's water supply does not appear adequate to meet the needs of its intend>O3,use for thapfollowinlg¢. "/ reason(s). oy�`,r N IQ<3 �® Reviewer's Signatures: 61��ti�i��;h� ,��5 Environ. Health: Date V7.17102.P/44, FA 1 , This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 WATER FACILITIES INVENTORY (WFI) Quarter: 2 Updated: 03/14/2025 orb- Washington Stan nepabnent°f FORM ��1 Health Printed: 4/24/2025 ONE FORM PER SYSTEM WFI Printed For: On-Demand Uh4fiMl of Cnaironula•n In!!!.nllh office al Drinking Water Submission Reason: Pop/Connect 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 Pik 05100 E BEARDS COVE MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS RICHARD DICKINSON [DEP. DIRECTOR] MASON COUNTY UTILITIES&WASTE DEPUTY DIRECTOR 100 W PUBLIC WORKS DRIVE MGMT SHELTON,WA 98584 RICHARD DICKINSON 100 PUBLIC WORKS DRIVE SHELTON,WA 98584 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN 4DDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)427-9670 x652 Owner Daytime Phone: (360)427-9670 x652 Primary Contact Mobile/Cell Phone: (360)490-0396 Owner Mobile/Cell Phone: (360)490-0396 Primary Contact Evening Phone: Owner Evening Phone: Fax: E-mail: rxxxxxxxxn@masoncountywa.gov Fax: (360)427-7772 IE-mail: rxxxxxxxxn@masoncountywa.gov ;SATELLITE MANAGEMENT AGENCY-SMA(check only one) X Not applicable(Skip to#12) 0 Owned and Managed SMA NAME: SMA Number. Managed Only El Owned Only E.WATER SYSTEM CHARACTERISTICS(mark all that apply) ❑Agricultural DHospital/Clinic X Residential Commercial/Business Industrial El School Day Care Licensed Residential Facility D Temporary Farm Worker El Food Service/Food Permit El Lodging El Other(church,fire station,etc.): 1,000 or more person event for 2 or more days per year 0 Recreational/RV Park 3.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) Association County 0 Investor 0 Special District City/Town Federal ❑Private State 400,000 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION co �` LIST UTILITY S NAME FOR SOURCE r z y m O T 11 = D _ m AND WELL TAG ID NUMBER. Z co Z c < c n m m-� n m 77 — 1 D A -1 il = Example: WELL#1 XYZ456 p y n m -o rn m m O -n O o D 9 A 4 -r. z B m m z D m O rrrrtt m 3 r y O y z O m IF SOURCE IS PURCHASED OR INTERTIE r r 0 0 m � 0 D FA - T z i7 0 0 i E I m c AA = INTERTIED, SYSTEM * -n m z T T D D r -i z O m m z , 11 z -1 m o z r 1 3 co 3 LIST SELLER'S NAME ID m m m m m a m x m z z 0 = m O co z $ r r r z r r m m xi m z D o m z O 0 o c m mm -+z O m = o Example: SEATTLE NUMBER r o 0 0 0 0 X 73 -< z -i r < 0 m z z z s —i z !n rn z m -o m SO1 WELL#1 AHB604 8" X X Y X 48 50 NE SE 30 23N 01W SO2 InAct 02/14/2000 WELL#2 12" X X X 398 20 SW SW 30 23N 01W S03 WELL#3 AHB606 8" X X Y X 445 40 SE SW 30 23N 01W SO4 WELL#4 AHB605 8" X X Y X 240 250 NE SE 30 23N 01W S05 WELL#5 AKP360 8" X X Y X 235 240 NE SE 30 23N 01W WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 05100 E BEARDS COVE 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?) 483 523 A. Full Time Single Family Residences(Occupied 180 days or more per year) 483 B. Part Time Single Family Residences(Occupied less than 180 days per year) 0 26. MUL1I-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) 0 0 0 B. Institutional,CommerciaVBusiness,School.Day Care,Industrial Services,etc. 1 1 0 28. TOTAL SERVICE CONNECTIONS 484 523 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 1100 ' 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? B. How many days per month are they present? 1 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 or customers have access to the water system each month? B. How many days per month is water accessible to the public'? 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 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 0 Update-No Change ❑Inactivate 0 Re-Activate ❑ 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: