The URL can be used to link to this page

Home My WebLink AboutWAT2025-00237 - WAI Health Waiver - 11/12/2025 WAT 2025- 00237 MASON COUNTY 4on,WA'Saeet Shelton.WA 98584 A Shelton:360-427-9670,Ext.400 '.-�: ; Public Health & Human Services Reffair.'i5n_775-446'Lrzt 4n11 — 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. BLD2025-01313 Part 1: Applicant! Parcel Identification Name of Applicant: B fU .•- PjarK Date: (I't2- 102.5.- qq J[dO � J'(p'q(p7 Mailing Address: /nZ.0 3 f-zite!t1,6 tki e ,901Phone: Parcel Number: 3G 1a 7S5/O .006a 1-ii E. KtJmotrnpt,K • asogz • Type of Water System Reason for Application Public/Community Water System(2 or more X Building permit connections) 0 Division of land: • 0 Individual water source(one connection), #of Parcels? SPL ❑ Well• 0 Boundary line adjustment ❑ Spring/surface water 0 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. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: ` Public Water System Name of Water System: £Ike. 1__ 1,,,,,,;r'i L ail livr ,Silcip.oi Water Facility Inventory(WFI)Number: 414 /�!J 7 (write"none"for two-party) 0 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. AI 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: Bull MI Pei Ma" This water system is abre 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 TI f K lI/al Phone 366-$ 7l°ZSe Signature of Water System Manager 3ij1A Alit_ Date /1-/2- 2025-- This form may be scanned and available for public view at www.masoncountywa.gov J:1EH forms\Drinking Water Revised 05/08/2024 Page 1 of 2 Group B Water Systems El 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. I Author of Statement Date Relationship to Applicant • • 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). Ell APPROVED Reviewer's Signatures: Environ. Health: IP Anderson 12,10ems Date 1 2/1 0/2025 This form may be scanned and available for public view at www.masoncountywa.gov Page_'or: WATER FACILITIES INVENTORY (WFI) Quarter: 1 Updated: 04/16/2025 �p Washington slate Department of FORM Printed: 12/10/2025 1# I-IealthONE FORM PER SYSTEM WFI Printed For. On-Demand eirit;aaJJ Enuironmr+aal!kali,: (�IrinofDrinknr�Wal`+ 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 44150 T LAKE LIMERICK WATER MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS CHRISTOPHER M. MCMULLEN [OPERATOR) LAKE LIMERICK COUNTRY CLUB INC GENERAL MANAGER 790 E ST ANDREWS DR CHRISTOPHER M. MCMULLEN SHELTON,WA 98584 CHRIS MCMULLEN WTR DEPT 790 EAST ST.ANDREWS DRIVE SHELTON,WA 98584 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)426-4563 Owner Daytime Phone (360)426-3581 Primary Contact Mobile/Cell Phone: (360)580-5271 Owner Mobile/Cell Phone: (360)426-4563 Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone. Fax: E-mail. wxxxr@lakelimerick.com Fax E-mail wxxxr@lakelimerick.com 11.SATELLITE MANAGEMENT AGENCY-SMA(check only one) x Not applicable(Skip to#12) O Owned and Managed SMA NAME SMA Number: ❑ Managed Only ❑ Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark aft that apply) ❑Agricultural ❑ Hospital/Clinic 111 Residential ❑ Commercial/Business ❑ Industrial ❑School Day Care ❑ Licensed Residential Facility ❑Temporary Farm Worker 181 Food Service/Food Permit ❑ Lodging INI Other(church fire station,etc): Igt 1.000 or more person event for 2 or more days per year X Recreational/RV Park 13.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) 0❑Association ❑CountyInvestor ❑Special Distract ❑City/Town ❑Federal XPrivate 0 State 320,000 - 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 3. COUNTY 4. GROUP 5. TYPE 44150 T LAKE LIMERICK WATER MASON A Comm 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION co 73 0 m z m D LIST UTILITY'S NAME FOR SOURCE rr- 0 y m co z z 1 m AND WELL TAG ID NUMBER. Z _ _ Cl) z z = r D ZO A 0 Example: WELL#1 XYZ466 c2 70 v o 0 m m Cl) 3 m O T O D m a z -, m m Z A > m Cl A m m 3 77 :; 73 � r vl A m Z , a IF SOURCE IS PURCHASED OR INTERTIE r r 0 0 0 O C z Z 0 0 O z 3 • c1 z z INTERTIED, SYSTEM 5 m m A m m > > r = zm 0 m m z0 -....2.. 1 T c 0 0 Q1 z LIST SELLER'S NAME ID � r r z r r rmr m , m z > O m z 0 is. c m m m z O m 0 m x Example: SEATTLE NUMBER r 0 0 G1 0 0 73 < A < r < 0 m z Z z 5 z �z L^u Z z v m SO2 WELL#2 AHA978 X X Y X 103 200 NE NW 27 21N 03W S03 WELL#3A AHA976 X X Y X 110 144 NW SW 27 21N 03W SO4 WELL#4 AHA973 X X Y X 92 74 SE SW 22 21 N 03W SO5 WELL#1 AHA974 X X Y X 89 49 NE NE 27 21N 03W S06 WELL#38 AHA975 X X Y X 167 194 SW SW 27 21N 03W $07 WELL#5 AHA977 X X Y X 110 35 NW SW 27 21N 03W S08 WELL#6 ALH995 X X Y X 429 248 SE SW 27 21N 03W DOH 331-011 (Rev. 06/03) DOH Copy Page: 2 WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 44150 T LAKE LIMERICK WATER MASON A Comm DOH USE ONLYI DOH USE ONLY ACTIVE CALCULATED APPROVED SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 844 Unspecified A. Full Time Single Family Residences(Occupied 180 days or more per year) 773 B. Part Time Single Family Residences(Occupied less than 180 days per year) 71 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) 354 354 B Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 3 3 28. TOTAL SERVICE CONNECTIONS 1201 29. FULL-TIME RESIDENTIAL POPULATION A How many residents are served by this system 180 or more days per yearn 1920 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'? 48 96 142 142 142 47 47 B How many days per month are they present? 30 30 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 1200 1200 1200 1200 1600 1600 1600 1600 1200 1200 1200 1200 or customers have access to the water system each month? B. How many days per month is water accessible to the public? 30 30 30 30 30 30 30 30 30 30 30 30 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 21 28 29 30 34 33 34 29 29 26 27 22 employees are present each month that are NOT already included in the residential population'? B. How many days per month are they present'? 30 30 30 30 30 30 30 30 30 30 30 30 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 ❑ Update-No Change ❑Inactivate ❑Re-Activate 0 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: 3 Intentionally left blank DOH 331-011 (Rev.06/03) DOH Copy Page: 4 ■rry' WS ID WS Name 44150 LAKE LIMERICK WATER Total WFI Printed: 1 DOH 331-011 (Rev.06/03) DOH Copy Page: 5 DOH 331-011 (Rev.06/03) DOH Copy Page: 1 ii/jA Washington State Department of 0 Healt v,vision of Environmental Health Office of Drinking Water Water Facilities Inventory(WFI) Report Create Date: 12/10/2025 Water System Id(s): 44150T 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 I