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Home My WebLink AboutWAT2025-00146 - WAT Application - 6/19/2025 • WAT 2025 - 00146 415 N.6*Street MASON Lour rry Shctton.WA 98184 Shelton:360-4 7-V67U. x4 400 COMMUNITY SERVICES Belau:361ha75 167,L•el400 AMC 36 -4$2--526i4,F141,409 Application for Determination of Water Adequacy Instructions 11. Complete Part 1. No determination can be made until Part 1 is rutty completed. 2. Complete only the portion of Part 2 apprvirio 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 i: Applicant! Parcel Identification Name on Applicant: Date:&Vicki Turner pate: 06 j 19,2025 Mailing Address' P d f341x 18S HoodSnnrt Ada 9f354/{3 Phone (253) 380-8335 Parcel Number: 42209.51-00070 Division-block- lot: ' Lot 70 and 71 Type of Water System Reason for Application RI Public/Community Water System(2 or more ® Building permit connections) ❑ Division of land. f] Individual water source (one conneabon}y rl of Parcels? SPL 0 Well 0 Boundary line adjustment 0 Spring/surface water ❑ Other(explain) 0 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 wet, check the PuNiciCornmanity Water signature required) 4 Syslem box. Signature %St�!k '!f'Ni?r Part 2: Water Connection Information Email Address amabeaver@yahoo.com Complete the section appropriate for the type of water connection being evaluated. Public Water System Name of Water System: LAKE CUSHMAN SYSTEM 5 Water Facility inventory(WFI)Number 035290 (write 'none'for two-party) ❑ 1 am the manager of this water system.The water system has been approved fort aecvices.There are presently__connection(s) in use This will be the connection El 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: tuii nrerw,nx This water system is able and willing to provide water to this{these)connections)without exceeding the limits of the water system or any limits set by state and local regulation. Print Name of Water System Manager CHEVON BROWNELL phone 360-877-2728 Signature of Water System Manager Date 06/20/2025 This farm may be scanned and readable for public view at www.co.ma$on.wa.us. 1'+11 Iunnv tNmliug*ma keam,1127 2112I • Individual Water Well fl Water wet report(attacned to application)- Depth it Q Well capacity Test(attached to app cation)_ dpm 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 welt report does not have a capacity test, a well capacity test.which provides stabilization of draw-down and recovery dale, must be performed by a licensed contractor. 0 Satisfactory bacteriological test (attach to application) Water Resource Inventory Area (WRIA) Development within which WRIA etto oiu co.rnason_wa ri&'piannlnit 14 15 16 22 Water use or limitation recorded hiIA Yes Weil Dntlod ........ ,. ............................... 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 • • Part 3: Mason County Community Services Evaluation (staff use only) V Satisfactory Oetarmination- This determination does not address adequacy of the dlslributiae system,guarantee an attieQuate Supply d water inrleliinitrrty in the future,or guarantee compliance with all applicable WDOE water rostrums regulatinns. Recommended approval Indicates requirements of Sanitary Code.Tillie 6,Chapter 6.68_040-Determination of Adequacy for Building Piarmits are satKfied Additional Growth Meraagenient requirements may apply. CAapier 36 70A RCA' Unsatisfactory Determination: Applicant's water supply does riot appear adequate to meet the needs at is intended use for the following reason(*) EH APPROVEC!eYlewer's Signatures: Environ, Heaittt: D.Anderson 08/01/2025 Date 8/1/2025 This form may be scanned and available for public view at tnfrvw.co.nwson.wa.us. la+.! 1 2 WATER FACILITIES INVENTORY (W Quarter: 1FI) Updated: 12/12/2024 FORM '' Washington Sulk Department of Printed: 8/1/2025 'Iry Health ONE FORM PER SYSTEM WFI Printed For: On-Demand DK•Ibi011 eeyy[+IUinmMN'I44'1/Cp111: Offk ofUrinkhlgWne.r Submission Reason: Pop/Connect Update RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@doh.wa.gov 4. GROUP I 5. TYPE 3. COUNTY l 1. SYSTEM 1D NO. 2. SYSTEM NAME Il 03529 0 LAKE CUSHMAN SYSTEM 5 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 TTN 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: lE-mail: CxxxxxxxL@LAKECUSHMANMC.COM Fax: E-mail.l bxxxxxxxs@lakecushmanmc.com 11.SATELLITE MANAGEMENT AGENCY-SMA(check only one) x Not applicable(Skip to#12) ❑ Owned and Managed SMA NAME: SMA Number: ❑ Managed Only El Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) ❑Agricultural ❑ Hospital/Clinic X Residential X(Commercial/Business ❑ Industrial ❑ School ❑ Day Care 0 Licensed Residential Facility 0 Temporary Farm Worker ❑ Food Service/Food Permit ❑ Lodging 0 Other(church,fire station,etc.): ❑ 1,000 or more person event for 2 or more days per year 1K Recreational/RV Park 3.WATER SYSTEM OWNERSHIP(mark only one) 4. STORAGE CAPACITY(gallons) li 5I9.300 CountyInvestor Special District ❑Association ❑ ❑ ❑City/Town ❑Federal Private ❑State - SEE NEXT PAGE FOR A COMPLETE LIST OF SOURCES- DOH 331-011 (Rev. 06/03) DOH Copy Page: 1 WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 13. COUNTY I 4. GAROUP l 5. TYPE 03529 0 1 LAKE CUSHMAN SYSTEM 5 MI omm 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION co x o z -� Cl) LIST UTILITY'S NAME FOR SOURCE r 0 N { p A 11 -o n AND WELL TAG ID NUMBER. Z Z % n m m p a { o > N N m Z .D m n T c v_ �� -o O ° Example: WELL#1 XYZ456 c z - D m c xi m m 3 z A -I �ti 3D ai z O A m tF SOURCE IS PURCHASED OR INTERTIE rn G) f r� O D U) G) al, z D n z O z Si; z c1 3 z z INTERTIED, SYSTEM T T 71 m D D r -I z O m m z S m y E p 1 O i 3 LIST SELLER'S NAME ID m m m m m -+ M m M m z z A O z _ c r- r r z r r m m rn m z z z0 m z O O O C m m 10 O m t7 Example: SEATTLE NUMBER r o o G) o o 7a z < 70 -I r -< o m z z z - A z m z z v m X X Y X 35 165 NW NE 29 23N 04W S01 WELL#3 AHB677 D-5 Shop X X Y X 55 178 SW NE 05 22N 04W SO2 WELL#5 AHB678 D-14 Park X X Y X 93 165 SW NE 05 22N 04W SO4 WELL#8 AHB679 D-14 Park X X Y X 40 60 SE SW 04 22N 04W S05 WELL#7 AHB675 D-6 1st Hole GC X X Y X 94 98 NE NW 09 22N 04W S06 WELL#11 AHB676 D-7 2nd Hole GC X X Y X 18 80 SW NE 16 22N 04W S07 WELL#4 D-9 Park X X Y X 145 NE NE 29 23N 04W S08 SO1 WELL#1 03527Y/LAKE CUSH#1 X Y X 192 110 NW NE 29 23N 04W S09 SO2 WELL#9 03527Y/LAKE CUSH#1 X DOH 331-011 (Rev. 06/03) DOH Copy Page: 2 WATER FACILITIES INVENTORY (WFI) FORM - Continued 3. COUNTY GROUP 5. TYPE 1. SYSTEM ID NO. 2. SYSTEM NAME 14. 03529 0 LAKE CUSHMAN SYSTEM 5 MASON A Comm 1 DOH USE ONLY!DOH USE ONLY! ACTIVE CALCULATED APPROVED SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 1605 Unspecified 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) A. Full Time Single Family Residences(Occupied 180 days or more per year) 642 B. Part Time Single Family Residences(Occupied less than 180 days per year) 963 1 26. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have?) 0 A. Apartment Buildings,condos,duplexes,barracks,dorms 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 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 16 16 128. TOTAL SERVICE CONNECTIONS 1621 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 1605 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? 2407 2407 2407 2407 2407 2407 2407 2407 2407 2407 2407 2407 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 35 35 180 525 1085 1050 1085 1085 525 180 35 35 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 2 2 2 3 4 4 4 4 3 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 0 Re-Activate 0 Name Change 0 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: 3 Intentionally left blank Page: 4 DOH 331-011 (Rev.06/03) DOH Copy WS ID WS Name 03529 LAKE CUSHMAN SYSTEM 5 Total WFI Printed:1 DOH 331-011 (Rev.06/03) DOH Copy Page: 5 DOH 331-011 (Rev.06/03) DOH Copy Page: 1 ismommimr ,0Washingtonstate Departmentof fr-1 Health Division of Environmental I learnt Office of Drinking Water Water Facilities Inventory(WFI) Report Create Date: 8/1/2025 Water System Id(s): 03529 Print Data on Distribution Page: ALL Print Copies For: DOH Copy Water System Name: ALL County: -- Any -- Region: ALL Group: ALL Type: ALL Permit Renewal Quarter: ALL Water System Is New: ALL Water System Status: ALL Water Status Date From: ALL To ALL Water System Update Date ALL To ALL Owner Number: ALL SMA Number: ALL SMA Name: ALL Active Connection Count From: ALL To: ALL Approved Connection Count ALL To: ALL Full-Time Population From: ALL To: ALL Water System Expanding ALL Source Type: ALL Source Use: ALL WFI Printed For: On-Demand DOH 331-011 (Rev. 06/03) DOH Copy Page: 2