Loading...
HomeMy WebLinkAboutWAT2025-00244 - WAT Application - 1/5/2026 WAT 2 ` , - `` _ - 415 N.6u'street 14% 584 2 -9Shelton,0,E t.400 Shelton:360-427-9670,Ext.40{i Public Health & Human Services Belfeir:360-275-4467,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 of Applicant V wk1/40c:0 [,oc e. Date: X 311 Mailing Address: (° 41 3v.:r,r,�u1t S;•,r�c.�.M u.�en ‘06, �Phone: S0 A -(o$0-ZS i'1 Parcel Number 12305-23-00010 Type of Water System Reason.for Application Building permit '' 1 -� 5 Public/Community Water System(2 or more connections) Q Division of land: Cl Individual water source(one connection), #of Parcels? SPL El Well 0 Boundary line adjustment O Spring/surface water 0 Other(explain) 0 Other(explain) 0 Replacement or Remodel(please indicate name If you have more than one residence connected of water system below if applicable—no to this well,check the Public/Community Water signature required) System box. Part WeterConnection information Complete section appropriate for the type of water connection being evaluated: , Public Water System Name of Water System: Tiger Lake Water Facility Inventory(WFl)Number: 04237 W (write"none"for two-party) �1 I am the manager of this water system.The water system has been approved for 40 services.There are presently 30 connection(s)in use.This will be the 31 connection. © Lam the manager of this system.This connection will be to upgrade or change the use of an existing connection on this system(i.e.:recreational to full time).Please indicate on the following line the nature of this change: This water system is able and willing to provide water to this(these)connection(s)without exceeding the limits of the water system or any limits set by state and local regulation, Print Name of Water System Manager Brandy Milroy Phone 360-877-5249 Signature of Water:System Manager � s<<=,i`.�I J r Date 04/15/2025 This form may be scanned and available for public view at www.masencountywa.sov I:IEH Forms\Drinking Water Revised 05/0$/2024 Page'1'of 2 { Group B Water Systems a Satisfactory bacteriological test within last year(attach to application). individual Water Well Water well report(attached to application). Depth ft. O Well capacity Test(attached to application) gpm. gpd• The welt 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. O. Satisfactory bacteriological test within last year(attach to application). individual Spring/Surface Water C1 WD0E permit(attach to application) Q 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 water indefinitely In the future,or guarantee compliance with all applicable WD0E water resource regulations. Recommended approval indicates requirements of Sanitary Code,Title 6,chapter 6.60:040-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 reasons). , Reviewer's Signatures: ` Ettvirort.Health: Date I tri,74 This form may be scanned and available for public view at www.masoncountvwa.go„ Page 2,on2 WATER FACILITIES INVENTORY (WFI) Quarter: 1 7 CORM Updated: 12110/2025 4 {1,"s h rkitiv s State D rtmort of C� "4ferri�ea l t y9(�G Printed: 1/5/2026 r ONE FORM PER SYSTEM WFI Printed For: On-Demand C7 ra far of t vinau&rn(nt 1 teach O17.,e D inAtnx Ra1cr' Submission Reason: No Change RETURN TO: Central Services-WFI, PO Box 47822,Olympia,WA,985O4-7822 or email wfi@doh.wa.gov 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP i 5. TYPE 04237 W TIGER LAKE TERRACE TRACTS MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS BRANDY A.MILROY[WATER RESOURCE MANAGJ MASON COUNTY PUD 1 WATER RESOURCE 21971 N HWY 101 BRANDY A.MILROY SHELTON,WA 98584 21971 N HWY 101 SHELTON,WA 98584 STREET ADDRESS IF DIFFERENT FROM 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)877-5249 Owner Daytime Phone: (360)877.5249x268 Primary Contact Mobile/Cell Phone: (360)490-2459 Owner Mobile/Cell Phone: (360)490-2459 Primary Contact Evening Phone: (xxx)xxx-xxxx Owner Evening Phone: (lax)-xxx-xxxx Fax: IE-mall bxxxxxm@mason-pudl.org Fax: (360)877-5339 IE-mail: bxxxxxm@mason.pudl.org 11.SATELLITE MANAGEMENT AGENCY`-SMA(check only one) 1O� Not applicable(Skip to#12) i�t Owned and Managed SMA NAME: MASON COUNTY PUD 1 SMA Number:111 0 Managed Only n Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) ©_Agricultural ®Hospital/Clinic 151 Residential O Commercial/Business O Industrial O School O Day Care O Licensed Residential Facility O Temporary Farm Worker o Food Service/Food Permit O Lodging isi Other(church,fire station,etc.): O 1,000 or mere person event for 2 or more days per year O Recreational/RV Park t3.°.. ATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) Association 0 County 0 Investor xSpeciai District 0 City/Town O Federal ❑Private Ei State 30,000 15 16' 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION re LIST UTILITY'S NAME FOR SOURCE z in AND WELL TAG ID NUMBER. z `z cr c 0 m 0 Example: WELL#1 XYZ456 > 0a F',) "kill y m m $ m r0 n r > A B m 2 dz i IF 2i 8 r m Z Z n .m e) m zm 5 :3 A g r i A.;;} al z 4 C IF SOURCE IS PURCHASED'OR INTERTIE F F rn g r? rL I o g E Gam) 1 5 z-t gj' m c gx 3 LIST SELLERI SDNARNE ID m m m 2 re m a a R. = m z z 3 A �, = ::„°, (20 z m y Zr w y ki. rrrzrr. mmNmz c) mzOt7OCm z �y z a in Example:_SEATTLE NUMBER r v c 0 Q a o u <. q -I .< o rn z'z 2 S RI 501 WELL#1<BBS710 X X Y X 75 50 NW NW 05 23N 01W . -, DOH 331-011(Rev.O6/O3) DOH Copy Page: 1. WATER FACILITIES INVENTORY (WFI) FORM Continued.. 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 04237 W` TIGER LAKE TERRACE TRACTS 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?) 28 - 40'. .. A. Full Time Single Family Residences(Occupied 180 days or more per year) 28 B. Part Time Single Family Residences'(OccuPlect less than ISO days per year) 0 28. 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. 1 1 0 0 128. TOTAL SERVICE CONNECTIONS 29 40 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year?. 68 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? B. How rimany`days per month are they present? 31.TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL. AUG SEP OCT N0V DEC A. How many total visitors,attendees,travelers,campers,patients or customers have access to the water system each month? B. How many days per month is water accessible to the public? 32. REGULAR NON-RESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. It you have Schools,daycares,or businesses connected to your water system,how many students,daycare children and/or 2 2 2 2 2 2 2 2 2 2 2 2 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 1 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: QUpdate-Change 0 Update.No Change 0 Inactivate 0 Re-Activate 0 Name Change 0 New System ❑Other 36. i certify that the Information stated on this WEI form is correct to the best of my knowledge. SIGNATURE: DATE: PRINT NAME: TITLE: DOH 331-011(Rev.06/03) DOH Copy Page: 2