HomeMy WebLinkAboutWAT2026-00036 - WAT Application - 3/16/2026 WAT ao , (-1")0 3(i) •
415 N.6th Street
Shelton,WA 98584
Shelton:360-427-9670,Ext.400
Public Health & Human Services Bel fair: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 on Applicant: i 4Arzwa_ A 4oa7/+C e-2) _Date: .843./aCb?,-
Mailing Address: =,2/6 /t AgE,Qe OIL/,#,O `S: Phone: ..e6D 731-4$16/
Parcel Number: .52S'D/-'..SQ —C=SY
Type of Water System Reason for Application❑ Pu lic/Community Water System (2 or more d& Building permit S Q30( U ood! I�f
S
connections) O Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water O Other(explain)
❑ 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:epeaCj� Pr7t(-`�"- ( pi V�.0ckti- J ��e
Water Facility Inventory (WFI) Number:..CD C.)r1, J (write"none"for two-party)
61 I am the manager of this water system. The water system has been approved for/IS services.There
are presently ((.7 connection(s)in use.This will be theA,y j-, 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 r v4N< c—`1 Phone NC, ( '6 /7`1' t
Signature of Water System Manager Date Q�(‘`—_),,, LS--
This form may be scanned and ava' abI or public view at www.masoncountywa.gov
J:\EH Forms\Drinking Water Revised 05/08/2024 Page I oft
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
• Individual Water Well
El 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)
O 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
s •
Part 3: Mason County Community Services Evaluation (staff use only)
ft 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.
El Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following .
reason(s).
SNZI Reviewer's Signatures:
Environ. Health: Date 3/16/26
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
1
WATER FACILITIES INVENTORY (WFI) Quarter: 2
Updated: 09/12/2022
FORM
I NB 'ag$�d Printed: 3/16/2026
ONE FORM PER SYSTEMWet',lepton State Department al WFI Printed For: On-Demand
HE ALT
Submission Reason: Pop/Connect
Update
RETURN TO: Central Services-WFI, PO Box 47822, Olympia,WA, 98504-7822 or email wfi@doh.wa.gov
4 SYSTEM ID,NO •, 2:":SYSTEM NAME_ 3.'COUNTY 4 GROUPr 5 TYP
E
05025II ,�.- BEACON POINT COMMUNITY CLUB
..,_
MASON
A Comm
6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS
KELLY R. BROWN[OPERATOR] BEACON POINT COMMUNITY CLUB WATER COMMITTEE
H2O MANAGEMENT SERVICES GARY JANISCH
PO BOX 2026 561 N BEACON PT LP
SHELTON,WA 98584 LILLIWAUP,WA 98555
STREET`ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS iF DIFFERENT PROM 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)427-0654 Owner Daytime Phone: (360)877-5789
Primary Contact Mobile/Cell Phone: (360)463-2923 Owner Mobile/Cell Phone: (360)490-1794
Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone: (xxx)-xxx-xxxx
Fax: IE-mail: hxxxxxxxs@gmail.com Fax: IE-mail: jxxxxxxx2@comcast.net
11.SATELLITE MANAGEMENT AGENCY SMA(check only one) n..- •:�:..
0 Not applicable(Skip to#12)
0` Owned and Managed SMA NAME: H2O Management Services Inc. SMA Number:140
x Managed Only
n Owned Only
12.WATER SYSTEM CHARACTERISTICS Ora,rk all that aPPIY) � � . ' _�_.. ;„.-
0 Agricultural Hospital/Clinic XResidential
0 Commercial/Business 0 Industrial OSchool
0,Day Care 0 Licensed Residential Facility ElTemporary Farm Worker
0 Food Service/Food Permit 0 Lodging []Other(church,fire station,etc.):
0 1,000 or more person event for 2 or more days per year ]$[Recreational/RV Park 0 RTCR Seasonal System
13.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons)
ix Association 0 County 0 Investor 0 Special District
0 City/Town 0 Federal 0 Private 0 State 51,701
a21 22 ' 23 24
15 SOURCE 16:',� _.,. 17"_ 18 � _. .. 19 20
.NAME INTERTIE ' SOURCE CATEGORY USE TREATMENTUSE TREATMENT'1 DEPTH 'SOURCE LOCATION''
UST
AND�WELLTAG ID NUMBERSOURCE � A "'Z,
a >o <n
Czi z ;3a
5� � � >.:
g'', tm'i
oe Example: WELL#1 XYZ456 r� �` ui D' ° r" m F. ?r tt�
§ r� 1 . D
m tmo P O O .. P,t .P ' z -i
z IF SOURCE IS PURCHASED OR INTERTIE r '� y O c� n , D g m 2 - v O .ii ' D rn z 0
3 INTERTIED, SYSTEM g -n. D D r O z 'O m m 2 ,ai' .4 ? Z O 2n O � ..9., 3 N'
c
LIST SELLERS NAME ID m m_m 2 m in m m ; m: z m cz, m z O O O 2 m m m.; C CO z Pri ,� rzz
!; Examples SEATTLE ', ' NUMBER r q,•:o O, :v. o �X C. �, 1 r -c_o m 2 z 2 5 ;fit -rz;
'S01 WELL#1 ABR956 6" X X Y X 203 60 NW SW 06 24N 03W
DOH 331-011 (12/2025) DOH Copy Page: 1