HomeMy WebLinkAboutWAT2025-00204 - WAT Application - 11/4/2025 WAT Z� � - OD
":. 415 N.6'1'Street
MASON COUNTY Shelton,WA 98584
(.7±W-1 r 5,1 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair:360-275-4467,Ext.400
&Aiding,Planning.Environmental Health,fommunityHealth 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
Name on Applicant Lochlan Glass Date: 10/06/2025
Matting Address: 71 N Kings Way S p Phone: 3603108399
Parcel Number: 422165200092 Division-block-lot: 12-92
Type of Water System Reason for Application
IR Public/Community Water System (2 or more ❑X Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
0 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.
Signature
Lcchian Glass(Oct 6,202510.05:04 POI)
Part 2: Water Connection Information Email Address lochlanglass@ma.il.com
Complete the section appropriate for the type of water connection being evaluated: 1,),, °)P 0\/ J
Public Water System hltlV 0 Li 2025
Name of Water System:
LAKE CUSHMAN SYSTEM 5 !1A30M CCU i I l'i:'NVIROII!OTAL HE\LT 11
Water Facility Inventory(WFI)Number: 035290 (write"none" for two-party) 1\''
❑ I am the manager of this water system. The water system has been approved fort ,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: Addition of permitted park model to existing property water line
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 Jesse Mathews Phone 360-877-9668
Signature of Water System Manager Date 10/06/2025
This form may be scanned and available for public view at www.co.mason.wa,us.
J:\EH toms\Drinking Water Revised 4/27/2021
PLN Approved
10/09/2025
Mason County Community Development
N. Kings Way S All Changes Subject to Approval
35' 0„
Disylaimcr
Mason County does no;regwre surveys for
i ' bonding.As a result,site plars may not reflect
/ 1 accurate data.It is the applicant's responsibility
i to compy with setback requirements.
/ 'SETBACKS ARE MEASURED FROM THE
/ FURTHEST PROJECTION OF THE
STRUCTURE
20x 30 RR5 STANDARD SETBACKS'
Driveway/Parking
Compacted Gravel Front Yard Setback 25'
.' q" Side&Rear Yard Setbacks:Residential
1/ '- litpTank dwetling(syaccessory structure(s)is 20'
OR 10%width of lot if not more than 100'wide
OR approved ADV
p 'Subject to EH Setbacks
/ u, 52
r
N
` 5'min tanks to
foundation/footings
O ' 1 e
/ J 'O
! ' 'On
a 7' _48'0°..._.____._...._....._.._ N
0.
co o_
o t4 Q'
'''.7 I
,5 4/ ./y 0,0„t• Existing 4
390S9h .1 16x16 Shed
o_
Cr.
1 O Exisitng
12x12
C Cabana
lg O �� 'i
/'�C
10'0"
6
oo oJ
Reserve Area Oscar OS N---�
r-----. A
0 b
L. _........._...•105'2 7/16"
EH Setbacks
A.) Drainfield/Reserve requires 10'setback from footing/foundations E H APPROVED
B.)Septic tank(s)requires 5'setback from all footing/foundations
C.)No foundation/Perimeter Drains within 30ft,downgradient of Rhonda Thompson 11/04/2025
Drainfield/Reserve area
D.)No Cut Bank(s)(greater than 5ft and over 45 degrees)within
50ft,down gradient of Drainfield/Reserve area
E.)Use approved mitigation from section C1-9 of the department of
ecology's"Criteria For Sewage Works Design,"when sewer
transport lines are within 10ft of water supply lines.
Parker Owners: Drawn: Notes: Contractor:
'1 N Kings Way South, Hoodsport, WA Lochlan & Rachel •Connected to
98548 42216-52-00092 Vivian Glass Meyers 2bd septic Pinnacle Construction
*Community 110 west K Street,
Water Shelton,WA
act Scale: Date: Rev: 'Site is flat 360-780-3890
Install New 15x26 lbd/lba MFH 1": 20' 10/4/2025 A and no
clearing to
be done.