HomeMy WebLinkAboutWAT2026-00027 - WAT Application - 2/23/2026 WAT 2026-00027
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C * TY
415 N..6'"Street
Shelton,1i/A 98584
,, , Shelton:360-427-9670',Ext.400
,7 Public Health & Human Servic 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: Cori DiSimone Date: February 23, 2026
Mailing Address: 1050 E. Daniels Road, Shelton 98584 Phone: 520-548-6771
Parcel Number: 32010-51-03002
Type of Water System Reason for Application
M Public/Community Water System (2 or more m Building permit BLD2026-00090
connections) O Division of land:
O Individual water source(one connection), #of Parcels? SPL
❑ Well O Boundary line adjustment
❑ Spring/surface water ❑ 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
Name of Water System: Cedar Grove (11914K)
Water Facility Inventory(WFI) Number: 11914K (write"none"for two-party)
l2 I am the manager of this water system. The water system has been approved for 88 services. There
are presently 59 connection(s) in use. This will be the 59th connection.
O 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:
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.
(owner)
Print Name of Water System Manager Matt Brown, General Manager Phone 877-408-4060
' '':::::.._...... ......._. 2/23/26
Signature of Water System Manager • Date
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.
O 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
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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 applicable1NDOE 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). _
Reviewer's Signatures:
Environ. Health: Date 3/4/26
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
WATER FACILITIES INVENTORY (WFI) Quarter: 1
� v vas Updated: 10/01/2025
FORM
Printed: 3/4/2026
..
ONE FORM PER SYSTEM WFI Printed For: On-Demand
NEALTil
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:DGR0UP 5 TYPE
11914 K " CEDAR GROV..
E MASON A Comm„
6 PRIMARY CONTACT NAME&MAILING ADDRESS 7„OWNER NAME&MAILING ADDRESS
JAMES S.JENSEN [MANAGER] WASHINGTON WATER SERVICE GENERAL MANAGER
EAST PIERCE DISTRICT-WWSC MATTHEW BROWN
PO BOX 44168 PO BOX 336
TACOMA,WA 98444 GIG HARBOR,WA 98335
STREET ADDRESS IF DIFFERENT FROMABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE
ATTN Aim
ADDRESS 5410 189TH ST E ADDRESS 14519 PEACOCK HILL AVENUE NW
CITY PUYALLUP STATE WA ZIP 98375 CITY GIG HARBOR STATE WA ZIP 98332-9240
9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION
Primary Contact Daytime Phone: (253)851-3422 Owner Daytime Phone: (253)851-4060
Primary Contact Mobile/Cell Phone: (253)606-7169 Owner Mobile/Cell Phone: (253)851-4060
Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone: ()ox)-xxx-xxxx
Fax: IE-mail: jxxxxxn@wawater.com Fax: (253)857-4001 IE-mail: Mxxxxn@wawater.com
11 SATELLITE MANAGEMENT M SMA(check only one)
O Not applicable(Skip to#12)
X Owned and Managed SMA NAME: Washington Water Service SMA Number 114
D' Managed Only
Di Owned Only
12.WATER SYSTEM CHARACTERISTICS(mark all that apply)
:.o Agricultural O Hospital/Clinic jgResidential
O Commercial/Business O Industrial USchool
O Day Care O Licensed Residential Facility OTemporary Farm Worker
O Food Service/Food Permit O Lodging DOther(church,fire station,etc.):
n 1,000 or more person event for 2 or more days per year D Recreational/RV Park O RTCR Seasonal System
13.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE,CAPACITY(gallons),
Association O County NI-investor O Special District
O City/Town O Federal O Private O State 14,455
TIE SOURCE CATEGORY USE" TREATMENT DEPTH SOURCE LOCATION
O
SOURCE NAME INTER;
LIST UTILITY'S NAME FOR SOURCE z z
Q >
AND WELL TAG ID NUMBER. A mG 0
to z" .` A
cc Example: WELL#1 XYZ456 5 ' :-o yr D m,-nEa, r m c g" <O a O
_ A m
1F SOURCE IS PURCHASED,OR INTERIM �. z z m' o E D) rnm 2 5 r 4 E> z O
z -n r N -n o 2 O. R t7 z > D z O z(-.)
z r 0. ,z
c "�IN1`ERTIED, � SYSTEM s �n ^n � '-n 'n -y -D r -+ a O m m �z �' m O�° r�,. � `D
LIST SELLER'S NAME ID m m - m m -� m x m z z z O .°i mx a c o . ao z
r r z r m m . A m z 0 0 0 C m mm,= . --�z� m � " G7:
Example:.SEATTLE" :- NUMBER r O .O G) v-'v o,; z =W r t o m z z z,$ z r z: ,41 m z -7 o m
601 Well#1 AHB674 X X Y X 228 50 NE NE 10 20N 03W
DOH 331-011 (12/2025) DOH Copy Page: 1