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HomeMy WebLinkAboutWAT2025-00242 - WAT Application - 12/2/2025 WAT . 2„ - Q, . 2- i � , MASON COUNTY 'm tit il*iti COMMUNITY SERVICES RFCEIV . . Building,Planning,Environmental Health,Community Health DEC 02 2025 415 N 6th Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 Belfair:(360)275-4467 ext 400 Elma:(360)482 est 400 , FAX(360)427,7787 "f.Alder Street Application for Determination of Water Adequacy Instructions k 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: ., ,;� Date• 1, Mailing Address: i) 1 .,�t ; IL,,f �ti` ion : ice '. t Parcel Number: O-1, > -.1 1≥_ Type of Water System. Reason for Application el Public/Community Water System(2 or more LESZI Building permit connections) O Division of land: ❑ Individual.water source(one connection), #of Parcels? SPL ❑ Well O Boundary line adjustment ❑ Spring/surface water 0 Other(explain) O Other(explain) O 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 'r _ ,. Name of Water System: _ :- � it2r1it �tl�'t:'6 4 `� � `,� Water Facility Inventory(WFI)Number: 0433'OtC1 (write"none"for two-party) O 1 am the manager of this water system.The water system has been apprpved foria7Pf services. There are presently connection(s)in use,This will be thy. ..._. connection. le I am the manager of this system.This connection will be to upgrade or change the use of an existing connection on this sys m(i.e.:recre tional to full time),Pease indicate on the following lipe the nature of this change: Ilk.) MP) i' o'k,, ei1Sl n, fie- 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 " its set by slat , hd local regulation.7 / Signature of Water System Manager y� � DatetitiS Y This form may be scanned and available for public view at www.co.mason.wa.us. J:AEH Forms\Drinking Water Revised 1/25/2018 Individual Water Well • 1 ❑ Water well report(attached to application). Depth ft. O Well capacity Test(attached to application) gpn gpd. E 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(attach to application). Water Resource Inventory Area (WRIA) Develop menl'Within-which ich A htfp/is,co,mason.wa.us/planning 14 15 16....---22---- 3 Water use or limitation recorder----------- --------N/A'� Yes TLell-Dritfi Date -......,„ .,,.��_ v---- Individual Spring/Surface Water -----7 ❑ WDOE permit(attach to application) O Method of disinfection O 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) Satisfactory Determination: This determination does not address adequacy of the distribution system,guarantee an adequate supply of iy( water indefinitely to 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. E 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: ry Environ. Health: Date /7,- (1/21(4Z016 CSD Director: Date 2 oft WATER FACILITIES INVENTORY (WFI) Quarter: 1 Updated: 02/11/2025 I TAWingtunSszir untaj FORM Updated: 12/2912025' ONE FORM PER SYSTEM WFI.Printed-For: On-Demand t)itduarr of t rr.I,un)rrental rrr.vtt1 Offp,4 Orr tiug i'Volre Submission Reason: Pop/Connect 1' Update RETURN TO: Central Services-WFI, PO Box 47822, Olympia,WA,98504-7822 or email wfi@doh.wagav 1. SYSTEM ID No. 2. SYSTEM NAME 3. COUNTY 4, GROUP 5..TYPE 88370 Y" TIMBERLAKE COMMUNITY CLUB INC MASON A. Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS MARCUS L.VIND[OPERATOR] TIMBERLAKE COMMUNITY CLUB INC PRESIDENT I' 2880 E TIMBERLAKE DR W TANNA AVILA SHELTON,WA 98584 2880 E TIMBERLAKE DR W 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)427-8928 Owner Daytime Phone: (253)377-4562 Primary Contact Mobile/Celt Phone:. (507)822-4684 Owner Mobile/Cell Phone: (206)240-1856 Primary Contact Evening Phone: (360)463.0664 Owner Evening Phone: (xxx)-xxx-xxxx Fax: IE-mail: wxxxxxxxxxxr@timberlakecc.con3 Fax: (360)427-1755 (E-mail: pxxxxxxxt©timberlakecc.com 11.SATELLITEMANAGEMENT;AGENCY-SMA(check only one)irg Not applicable(Skip to#12) 0 Owned and Managed SMA NAME: SMA Number Managed Only 0 Owned Only 12.WATER SYSTEM CHARACTERISTICS(marts all that apply) _ l o Agricultural El Hospital/Clinic N Residential o Commercial/Business 0 Industrial 0 School o Day Care 0 Licensed Residential Facility o Temporary Farm Worker o Food Service/Food Permit 0 Lodging 0 Other(church,fire station,etc.): 1,000 or more person event for 2 or more days per year 154 Recreational/RV Park 13 WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) xi Association ©CountyInvestor 0 Special District City/Town ❑Federal 0 Private 0 State 260,000 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION A a m $ LEST UTILITY'S NAME FOR SOURCE r z AND WELL TAG ID NUMBER. rrr z c' m' . c m .. n ., ra ? Example: WELL#1 xYZ456el) v [mA Ap .-n ° m m m O mr. a <m m_ — O in 7J z" IF SOURCE IS PURCHASED oB INTERTIE r--r- y 0 3► `M�ttt O 2 O ta -1 m c = INTERTIED SYSTEM 'n 11 l 7n > D r O v fn c O ;i2i`O g I . "" LISTSELLER'SNA61E It) m m m 2 m m 1��'{{ D m s m g" z xr o 0 3 c -it mil 2 a m z i- r-.r r1t m z A m 2 O 4 O m m Z ;O. "m Gt , 4 Example: SEATTLE NUMBER" r a o s 1 0 73 as -< 23 -1 r . 0 m z z z 5 ?s zi z ...or- z -.-o `m; $01 WELL#1 ABR116 8" X X Y X X" 342 180 NW SE 18 20N 02W N 802 WELL#2 AFK577 8" X X Y X X 280 250 NW SE 18 20N 02W S03 WELL#3.AEC923 X X Y X X 373 28D NW SE 18 20N 02W SO4 WF(S1,$02,S03) X X V X 280 710 NW SE 18 20N 02W DOH 331-011 [Rev.06/03) DOH Copy Page: 1 E i WATER FACILITIES INVENTORY (W.FI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 68370 Y TIMBERLAKE COMMUNITY CLUB INC 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?) 920 Unspecified A. Full Time Single Family Residences(Occupied 180 days or more per year) 620 B. Part Time Single Family Residences(Occupied less than 180 days per year) 300 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 endlorTransiant Accommodations(Campsites,RV sites,hotel/motel/overnight units) 0 0 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 90 90 128.TOTAL SERVICE CONNECTIONS 1010, 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year'? 1400 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? 200 200 250 300 400 600 800 900 400 300 250 200 B. How many days per rnonth are they present? 31 28 31 30 30 30 31 31 30 31 30 31 r r 31. TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG ; SEP OCT NOV DEC' A. How many total visitors,attendees,travelers,campers,pollards 100 100 100 300 400 700 700 800 500 300 200 200 or customers have access to the water system each month? B, Now many days per month is water accessible to the public? 31 28 31 30 30 30 30 30 30 30 30 31 ) rr i432. 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 andfor 10 10 10 10 10 10 10 10 10 10 10 10 employees are present each month that are NOT already included in the residential population? B. How many days per month are they.present? 20 20 20 20 20 20 20 20 20 20 20 20 33. ROUTINE COLIFORMSCHEDULE 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 3YEARS (One Sample per source by time period) .35, Reason for Submitting WFI: rr--tI O Update-Change O Update-No Change O Inactivate Ll Re-Activate O Name Change O New System ❑Other 36. Icertify 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.06103) DOH Copy Page: 2 .