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Home My WebLink AboutWAT Application - 3/3/2025 WAT - 415 N.6th Street 4e.1101 MASON COUNTY Shelton,WA 98584 i COMMUNITY SERVICES Shelton:360427-9670,Ext.400 Belfair:360-275-4467,Ext.400 %psi 1y ' Building Planning,Environmental Health,Community Health Etna: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 Name on Applicant: Robert&Sandy Burns Date: 3/3/25 Mailing Address: 13312 197th St E Phone: 253-732-3780 Parcel Number: 423185100037 Division 4 Lot 37 Type of Water System Reason for Application • Public/Community Water System (2 or more O Building permit --foLa..0a2�J"00a1'16 connections) ❑ Division of land: ❑ Individual water source (one connection), # of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other (explain) ElOther (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. Efi fvc( for �rciorn Part 2: Water Connection Information ('- SF,Q Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: Lake Cushman System 3 Water Facility Inventory (WFI) Number: 03528F (write "none"for two-party) O 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 NON O(i.1: 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 CH VON BROW. LL Phone 360-877-2728 Signature of Water System Manager C o) ,� 7 Date 03/04/2025 This form may be scanned and available for public view at www.co.mason.wa.us. 1. 1[11 Foim.i Drinking Water Revised 4/27/2021 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 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 0- 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 requirements may apply. Chapter 36.70A RCW. Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Reviewer's Signatures: Environ. Health: EAD/T Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2or2 WATER FACILITIES INVENTORY (WFI) Quarter: 2 Updated: 12/12/2024 Washington State Department of FORM P Health Printed: 7/18/2025 '� ONE FORM PER SYSTEM WFI Printed For: On-Demand rcz,,,rr,J Lu,rrurmmnrar Huilth Ofiar u(Dnnking Wnfo 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 03528 F LAKE CUSHMAN SYSTEM 3 MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS CHEVON A. BROWNELL LAKE CUSHMAN MAINTENANCE CO. PRESIDENT,JUNE 2023- 3740 N. LAKE CUSHMAN RD. ELIZABETH STEPHENS HOODSPORT,WA 98548 3740 N. LAKE CUSHMAN RD. HOODSPORT,WA 98548 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)877-2728 Owner Daytime Phone: (360)877-9668 Primary Contact Mobile/Cell Phone: (912)227-6426 Owner Mobile/Cell Phone: Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone: Fax: E-mail: CxxxxxxxL@LAKECUSHMANMC.COM Fax: IE-mail: bxxxxxxxs@lakecushmanmc.com 11.SATELLITE MANAGEMENT AGENCY-SMA(check only one) X Not applicable(Skip to#12) O Owned and Managed SMA NAME- SMA Number: 0 Managed Only ▪ Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) Agricultural 0 Hospital/Clinic X Residential Commercial/Business 0 Industrial 0 School Day Care D Licensed Residential Facility 0 Temporary Farm Worker ▪ Food Service/Food Permit ❑ Lodging 0 Other(church,fire station,etc.): O 1,000 or more person event for 2 or more days per year 0 Recreational/RV Park — 13.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) Association ❑County ❑Investor ❑Special District ❑City/Town D Federal M Private 0 State 138,900 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION -oco 1-1 a o xt z m C) LIST UTILITY'S NAME FOR SOURCE r z z co - v cn AND WELL TAG ID NUMBER. 2 z Cl) j 0 c) T m 0 O 0 D cn co m 2 = r D O p cc Example: WELL#1 XYZ456 33 m cn D m m to 3 m O m_ O D D m a z -1 z IF SOURCE IS PURCHASED OR INTERTIE r mr z z D m O g m m m - - -� r m 3 m to z O z r r ti G) O * * D O > N 6) -mj z �7 0 0 0 z-{ 3 P m z `r c INTERTIED, SYSTEM -n m r m > > rr- -1 z O m m z D D > z m m o z r n 3 z 3 LIST SELLER'S NAME ID r m m Z m m m m z m z > C) m z O O O C m m m _,co O m = 0 Q m Example: SEATTLE NUMBER r v o G) o o v -< X 1 r -< o m z z z 5 J -i z m rn z 73 v m SO1 WELL#2 AHB682 X X Y X 95 275 NE NE 18 23N 04W SO2,WELL#10 AHB683 X X Y X 154 150 NE SW 18 23N 04W DOH 331-011 (Rev.06/03) DOH Copy Page: 1 WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 03528 F LAKE CUSHMAN SYSTEM 3 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?) 397 512 A. Full Time Single Family Residences(Occupied 180 days or more per year) 159 B. Part Time Single Family Residences(Occupied less than 180 days per year) 238 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) 0 0 0 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 4 4 0 28. TOTAL SERVICE CONNECTIONS 401 512 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 398 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? 595 595 595 595 595 595 595 595 595 595 595 595 B. How many days per month are they present? 8 8 8 15 25 25 25 25 15 8 8 8 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 10 10 51 150 310 310 310 310 150 51 10 10 or customers have access to the water system each month? B. How many days per month is water accessible to the public? 31 28 31 30 31 30 31 31 30 31 30 31 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 13 13 13 13 13 13 13 13 13 13 13 13 employees are present each month that are NOT already included in the residential population? B. How many days per month are they present? 21 21 21 21 21 21 21 21 21 21 21 21 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 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 ❑ 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: DOH 331-011 (Rev.06/03) DOH Copy Page: 2