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Home My WebLink AboutWAT2025-00121 DUPLEX SIDE A - WAT Application - 6/11/2025 RECE VED WAT 2 025 JIJN 11 2025 iggit MASON COUNTY 815 W.Aktfer 415 N.6th Street Shelton:360-427-9670, x. ./ Public Health & Human Services Belfair: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: ill/51/ ° Date: 7 /t)— Z� Mailing Address: To iApy, WAPhone: 253 377 £ '7 Parcel Number: JZ . /°7f 09 354,2Cl 122.11.-50 - 9 -39 A Type of Water System Reason for Application /Public/Community Water System (2 or more t127nBuilding permit connection's) 0 Division of land: ❑ Individual water source(one connection), #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 a plicable—no to this well, check the Public/Community Water signat System box.Part 2: Water Connection Information Puptei( 5,1* (11) Complete the section appropriate for the type of water connection being evaluated: `!,, •- Public_1 Water l System Name of Water System: L-a -elcul�,1 d �v ( `a/y-Q- Wa� Water Facility Inventory(WFI) Number: `. 0 O (write"none"for two-party) XI I am the manag r of this water system.The water system has been apprg,'ed for-1 /S services. There are presently 4'115 connection(s)in use.This will be the ection. 0 I am the manager of this system. This connection will be to upgrade-or , ange 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 Phone .4O Z`�/�t 6 !/ Signature of Water System Manager dr"?----\-__Pate 4—V.24726 This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2 Group B Water Systems ❑ 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. 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 syst€'Ir Tjr) e an adequate supply of water indefinitely in the future,or guarantee compliance with all applicable D(, resource regulations. Recommended approval indicates requirements of Sanitary Code,Title 6,Chapte .( Determination of Adequacy RCW.Building Permits are satisfied. Additional Grq, h Managegpj)t uiremer rt a ly. Chapter-184❑ Unsatisfactory Determination: CCU-7)-4- � .9 2�z5 Applicant's water supply does not appear adequate to meet the needs of ��t0d d use for the following reason(s). (✓A "4'/I/,1, q/T•), - Reviewer's Signatures: Environ. Health: Date W?(?0?S. This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER FACILITIES INVENTORY (WFI) Quarter: 1 Washington State Department FORM Updated: 03/26/2025 Health Printed: 7/10/2025 ONE FORM PER SYSTEM WFI Printed For: On-Demand Division of Environmental Health Office of Drinking Water Submission Reason: No Change 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 45090 R LAKELAND VILLAGE WATER MASON A Comm .6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS RICHARD A.ANDERSON [MANAGER] LAKELAND VILLAGE WATER CO OWNER CONTACT PO BOX 108 RICHARD A.ANDERSON ALLYN,WA 98524 PO BOX 108 ALLYN,WA 98524 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS 470 E COUNTRY CLUB DR ADDRESS CITY ALLYN STATE WA ZIP 98524 CITY STATE ZIP 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)275-2474 Owner Daytime Phone: (360)275-2474 Primary Contact Mobile/Cell Phone: (360)801-0630 Owner Mobile/Cell Phone: (360)801-0351 Primary Contact Evening Phone: Owner Evening Phone: Fax: (360)275-0266 IE-mail: Lxxxxxxxxl@msn.com Fax: IE-mail: Lxxxxxxxxl@msn.com 11.SATELLITE MANAGEMENT AGENCY-SMA(check only one) Not applicable(Skip to#12) ▪ Owned and Managed SMA NAME: SMA Number: ▪ Managed Only n Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) n Agricultural O Hospital/Clinic Residential X Commercial/Business O Industrial n School Day Care D Licensed Residential Facility p Temporary Farm Worker X Food Service/Food Permit o Lodging n Other(church,fire station,etc.): El 1,000 or more person event for 2 or more days per year O Recreational/RV Park 13.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) ❑Association n County Investor ❑Special District ❑City/Town Federal �Private �State 240,000 -SEE NEXT PAGE FOR A COMPLETE LIST OF SOURCES - WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 45090 R LAKELAND VILLAGE WATER MASON A Comm 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION ci) xi * v D m LIST UTILITY'S NAME FOR SOURCE r Z z N _ D AND WELL TAG ID NUMBER. F G7 -< O z z= D m cn z Z — C) -n m i0 C) a C) c c Example: WELL#1 XYZ456 > v - cn D m m m m0 i— _ OO C m v j 0 'n * * z m c) m cn 3 m O O D D ill a z i a m m z > m O z m m g Xi r Xi ,i r cn O O z IF SOURCE IS PURCHASED OR INTERTIE rr- Po O C 3 C) m z i o O i 3 D m c 2 `2 * p... O z O m m O z r c INTERTIED, SYSTEM n rn D > r -a z O m m z i z i m c r -Oi 3 cn LIST SELLER'S NAME ID r- i- i- z r i- m m x m z D o m z O O O m m m i z O m = o -- Example: SEATTLE NUMBER r 0 0 6) 0 0 xi xi -( XI -a r -< 0 m z z z ,'0 -i • cn z Xi -Ti m S01 WELL#1 No tag X X N X 407 40 SE NE 19 22N 01W S02 WELL#2 AFK552 X X Y X 294 155 SW SE 17 22N 01W S03 WELL#3 AFK553 X X Y X 205 250 SW NE 20 22N 01W S04 WELL#4 AHA980 X X Y X 211 400 SE NW 20 22N 01W S05 WELL#5 AFK551 X X Y X 105 140 NE SW 17 22N 01W S06 WELL#6 AKM942 X X Y X 406 400 NW NW 20 22N 01W WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM lb NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP, 5. TYPE 45090 R LAKELAND VILLAGE WATER 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?) 898 975 A. Full Time Single Family Residences(Occupied 180 days or more per year) 793 B. Part Time Single Family Residences(Occupied less than 180 days per year) 0 26. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have?) A. Apartment Buildings,condos,duplexes,barracks,dorms 40 B. Full Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied more than 180 days/year 105 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. 20 20 0 128. TOTAL SERVICE CONNECTIONS 918 1 975 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 2023 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 many days per month are they present? 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 88 148 267 529 870 934 1594 1438 973 384 94 59 or customers have access to the water system each month? B. How many days per month is water accessible to the public? 20 20 20 20 20 20 20 20 20 20 20 20 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 17 17 17 17 17 17 17 17 17 17 17 17 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 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: O Update-Change O Update-No Change O Inactivate O Re-Activate O Name Change O New System O 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: ,,..,,.,.,. .,�, ir.'-- nr,nn" .-...... n,...... 0