The URL can be used to link to this page

Home My WebLink AboutWAT2025-00068 - WAT Application - 2/18/2025 .i.;.;..--. - '1,Q ',MASON COUNTY oet l COMMUNITY DEVELOPMENT Permit Ass stance Cente•.Building.Pgnning l WAT age - 000( 415 N 6'' Street, Bldg 8. Shelton WA 98584. Shelton (360)427-9670 ext 400 Belfair.( 0(360))75-4467 ext 400 Elma (360)482-5269 ext 400 -27-7787 Application for Determination of Water Adequacy Instructions 11 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 I 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 1 1r\tft-11stik 1+� 6C2\„ak.\ Date - Mailing Address ?0 CI S;Q r Ck nn. Phone `�� C Parcel Number ia.S5 �` Type of Water System Reason for Application Building permit g1.�2o0S `tom 2d Public/Community Water System (2 or more 0 Dividing of land connections) ❑ Individual water source (one connection). #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) 0 Replacement or Remodel (please Indicate name of water system below if applicable - no If you have more than one residence connected signature required) to this .re!t check the Public/Community Water s;g" 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 Pirate's Cove Water Facility inventory (WFO Number 67740 K (write"none' for two-party) Ed I am the manager of this water system. The water system has been approved fornnectlon94 services. There are presently 76 connection(s) in use This will be the 0 I am the manager of this system This connection will he 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 willinglltoprwater to thi and s (thee)regulation without exceeding the limits of the water system orany set by Date 03/04/2025 Signature of Water System Manaaer - �f This form may be scanned and available for public view at www.co.mason'wa.us. t I II/.inns I)rml.m_11at; 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) ❑ 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 • Part 3: Mason County Community Services Evaluation (staff use only) 7 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 requirementsp y• Chapter 36.70A RCW. 4,. Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intendOi use for th4Aollowing fr reason(s). 4/ C040 �`U Reviewer's Signatures: Environ. Health: Date y(*)#6064 yF 417y This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER FACILITIES INVENTORY (W Quarter: 1FI) 01/08/2025 Updated: FORM /�' w �sateI ofPrinted: 5/1/2025 Ii Health ONE FORM PER SYSTEM WFI Printed For: On-Demand u,i;,;,,,gc„a;rWi„�: i'loath Submission Reason: No Change U�c,•,/ ri„kms Wnftr RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@d4 .wa GROUP 5. 5. TYPE II 3. COUNTY 1. SYSTEM ID NO. 2. SYSTEM NAME A Comm 67740 K PIRATES COVE COUNTRY CLUB MASON T OWNER NAME 8 MAILING ADDRESS 6.PRIMARY CONTACT NAME&MAILING ADDRESS BRANDY A. MILROY[WATER RESOURCE MANAG] MASONY A.O MNTYILR PUD 1 WATER RESOURCE 21971 N HWY 101 BRAND21971 N HWY 101 SHELTON,WA 98584 SHELTON,WA 98584 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN 4TTN ADDRESS -. ITYADD S STATE ZIP CITY STATE ZIP CITY 10.OWNER CONTACT INFORMATION 9.24 HOUR PRIMARY CONTACT INFORMATION Owner Daytime Phone: (360)877-5249 x268 'rimary Contact Daytime Phone: (360)877-5249 Owner Mobile/Cell Phone: (360)490-2459 'rimary Contact Mobile/Cell Phone: (360)490-2459 Owner Evening Phone: (xxx)-xxx-xxxx 'rimary Contact Evening Phone: (xxx)-xxx-xxxx Fax: E-mail: bxxxxxm@mason-pud1.org Fax: (360)877-5339 E-mail: bxxxxxm@mason-pudl.org SATELLITE MANAGEMENT AGENCY-SMA(check only one) ❑ Not applicable(Skip to#12) SMA Number.111 la Owned and Managed SMA NAME: MASON COUNTY PUD 1 ❑ Managed Only Owned Only .WATER SYSTEM CHARACTERISTICS(mark all that apply) ❑Hospital/Clinic li Residential ❑Agricultural ❑ Industrial ❑School ❑Commercial/Business Temporary Farm Worker 0 Licensed Residential Facility ❑ ❑ Day Care 0 Lodging ❑Other(church,fire station,etc.): Food Service/Food Permit Recreational/RV Park El1,000 or more person event for 2 or more days per year ORAGE CAPAC gallons WATER SYSTEM OWNERSHIP,Pk�S�MY one ❑Investor Special District ❑Association ❑County ❑State 34,000 ❑ ❑Private ❑City/Town Federal 2Y 28 24 17 18 19 20 21 SOURCE LOCATION 15 16 TREATMENT DEPTH SOURCE NAME INTERTIE SOURCE CATEGORY USE * p D Z uJ uJ LISTUTILISNAMEFORSOURCE r- LZ1 rn m O A 1= n , m vj c " � mo > AND WELL TAG ID NUMBER. z z p 4 O y D � v, T Z y m n r m C � <m m{ p Z .� c v to D • z uJ m 3 71 o ,. o 5 D7o AO O c Example: WELL#1 XYZ456 A rr� r" Cl -4 r y 3 D m c Z INTERTIE m F ui O 0 Dg * D O D cn O Ti D p D z O0 m O c r ..� W i m IF SOURCE IS PURCHASED OR * m 7I p m m D D Z INTERTIED, SYSTEM r -+ z O m m Z =i � , c s m� -�O O c ID m m m Z E m m m m Tiz D A m z O O O m rnm m 3 m y z >' � m LIST SELLER'S NAME r r r cr Example: SEATTLE NUMBER r v o O v v < r < o m Z Z Z A 14Z 7 94 NW SW 08 21N 01W Ell X X Y X SO2 WELL#2 AHA983 S03 WELL#3 AEC892 X Y X 180 100 NW SW 08 21N 01W X WATER FACILITIES INVENTORY (WFI) FORM - Continued YSTEM ID NO. 2. SYSTEM NAME 3. COUNTY GROUP TYPE PIPS67740KPITESCOVECOUNTRY CLUBMASON14. 15. A Comm DOH USE ONLY! DOH USE ONLYI ACTIVE CALCULATED SERVICE ACTIVE APPROVED VISO X SINGLE FAMILY RESIDENCES(How many of the following do you have?) CONNECTIONS CONNECTIONS CONNECTIONS A. Full Time Single Family Residences(Occupied 180 days or more per year) 7794 B. Part Time Single Family Residences(Occupied less than 180 days per year) 34 43 26. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have?) J 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,hoteUmotel/overnight units) B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 0 0 0 0 0 0 128. TOTAL SERVICE CONNECTIONS 77 29. FULL-TIME RESIDENTIAL POPULATION 94 A. How many residents are served by this system 180 or more days per year? 85 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'? 20 42 86 86 20 B. How many days per month are they present? 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 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 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) $5. Reason for Submitting WFI: 0 Update-Change ❑ Update-No Change ❑Inactivate ❑Re-Activate El Name Change El New System El 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: