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HomeMy WebLinkAboutWAT2026-00043 - WAT Application - 3/16/2026 WAT 1)`,2,1.49 - 066,-122 22 y k MASON COU TY N 415 N.6th Street ' Shelton,WA 93534 Shelton:360-427-9670,Ext.400 *° "u Sei VI 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: CO 16V �utt1 ' Date: `lb- & Mailing Address: Zb U 5 ,z7LJ VAtky,) , S�, .t VIA-Phone: 3.t o - . - 5'3 Parcel Number: 32232-75-90032 Type of Water System Reason for Application V Public/Community Water System (2 or more V Building permif j 262..t4-col 14 connections) O Division of land: ❑ Individual water source (one connection), #of Parcels'? SPL ❑ Well O 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: Union Water Facility Inventory(WFl) Number: 51920 W (write"none"for two-party) O I am the manager of this water system.The water system has been approved for services.There are presently connection(s) in use.This will be the connection. lS1 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: Inactive to Active Connection 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 ,,e,..( f `4,4 ir Date 02/23/2026 This form may be scanned and available for public view at www.masoncountywa.gov 7:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 oft 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) qpm 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 - O 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) X 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 ROW. ❑ Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of Its Intended use for the following reason(s).. EH APPROVED Reviewer's Signatures: 3/16/2026 Environ. Health: Andeson 03/16/2036 Date r This form may be scanned and available for public view at www.masoncountywa.gov Page 2 oft WATER FACILITIES INVENTORY (WFI) Quarter: 1 ° Updated: 12/10/2025 ��" + ��� a® FORM ii m• :v Printed: 3/16/2026 ONE FORM PER SYSTEMWashington St•le Omoartswnt of WFI Printed For: On-Demand Submission Reason: Pop/Connect Update 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 COUNTY4 GROUP TYPE 5i 92©W..<.., .,: UNION ,._ ...., . ._� • ..� „-... ....,,,.. �....,,_,;•„,.. _ ,-, ..M_,..._,L:'.____.-'_•:...... , N MASON A Gomm fi PRIMARY CONTACT NAME&MAILING ADDRESS; 7,..OWNER'NAME&MAILING ADDRESS , BRANDY A. MILROY[WATER RESOURCE MANAG] MASON COUNTY PUD 1 WATER RESOURCE 21971 N HWY 101 BRANDY A. MILROY SHELTON,WA 98584 21971 N HWY 101 SHELTON,WA 98584 STREET.iADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS....___—DIFFERENT ABOVE ;; ATTN ....._,.�;a. .. e,.,M. ..��,,u,�_ �_, ,, „�- _, ATTN _..��._.��— �_��_,- _. ,a_ <_-W�_— _�W ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP 9 24;HOUR'PRIM TACT INFORMATION '- 10.''OWNER,CONTACT INFORMATION'',, A RYCON Primary Contact Daytime Phone: (360)877-5249 Owner Daytime Phone: (360)877-5249 x268 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: (xxx)-xxx-xxxx ( )360 877-5339 IE-mail bxxxxxm@mason-pud1.org Fax: IE-mail: bxxxxxm@mason-pud1.org Fax: 1t SATELLITE MANAGEMENT AGENCY SMA(check only one) D Not applicable(Skip to#12) x Owned and Managed SMA NAME: MASON COUNTY PUD 1 SMA Number:;111 Q Managed Only Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply)` a , _.._. .., . :,._. . .:� ......, a . ------ _ — O Agricultural O Hospital/Clinic XResidential >14 Commercial/Business ❑ Industrial ❑School Q Day Care O Licensed Residential Facility Temporary Farm Worker X Food Service/Food Permit O Lodging XOther(church,fire station,etc.): O 1,000 or more person event for 2 or more days per year 0 Recreational/RV Park O RTCR Seasonal System 13.WATER SYSTEM OWNERSHIP(mark only one) 14 STORAGE CAPACITY(gallons) ❑Association O County 0 Investor Special District O City/Town ❑Federal O Private 0 State 74,100 15 16 17- "1'8 19 20 21 22.` 23 24 , -SOURCE NAME. INTERTIE DEPTH SOURCE LOCATION, SOURCE CATEGORY USE' TREATMENT LIST UTILITY'S NAME ,, v g 0 FORSOURCE _ � � - z z -.: m ,_ , -i A to AND WELLTAG ID NUMBER E .. 2, 2; -mt 8 x r x o h '` 13 rn „ *. m 10 _ A O Example WELT,#t XXZ456 • - � � A � n -zn � � � m O � Q q <--,,;", ill� + °z -+` IF SOURCE IS INTER ED, SYSTEM m m m = m z > > a m -zqi D z -n o.•.. •.E n c s ,, 3 SELLER'S r- z mmmnrrxmzmmz O 2-3 BF UST SELLERS NAME PURCHASED- INTERTIE Y" ,r- W A, ry ID mxmzzioO x "o O IA NUMBER .4 m z r- .-c ,m z O,O, O -.m�. � o m O Example: SEATTLE. r. 6; o a_ 6,�.6 ?o; -� :0 1 r^ .�_ v m z z z 5 n-]a m y z ow- -m S01 Well#1 BBS712 10" X X Y X 84 40 NW SW 32 22N 03W S02 Well#2 ABR118 16"to 10" X X Y X 259 234 NE SW 32 22N 03W DOH 331-011 (12/2025) DOH Copy Page: 1 WATER FACILITIES INVENTORY (WFI) FORM - Continued A. M ID NO ' :2..SYSTEM NAME a SYSTEM `3: COUNTY '4.i.GROUP '5 TYPE" : 59S20W UNION MASON A Comm ; DOk�USE O L1QH USE O NLY, I SERVICE- 'ACTIVE tATED_ ON S CONNECTIONS -APPROVED'" CONflEC CONNECTI T[ONS -= 2 LE FAMILY RESIDENCES(How many of-the following,do you have?) 267 ,;" 2534• ' : A. Full Time Single Family Residences(Occupied 180 days or more per year) 234 B. Part Time Single Family Residences(Occupied less than 180 days per year) 33 R IAL BUILDINGS 26. MUL-Tt„F'AMILY.' ESIDENT DINGS.(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 H y ow man of the following; have?)following-do A.Recreational Services and/or Transient Accommodations(Campsites,RV sites,hotel/motel/overnight , �' ( p otel/motelloverni ht g units) 0 ,Q 0 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 8 8 8 128. TOTAL SERVICE CONNECTIONS ` '' '275 .'',261.,„,;' 29. PULL-TIME RESIDENTIAL OPULATION A. How many residents are served by this system 180 or more days per year? 585 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? 20 4 4 10 10 50 50 50 16 4 4 20 B. How many days per month are they present? 31 28 31 30 31 30 31 31 30 31 30 31 31.TEMPORARY..&TRANSIENT USERS JAN ';FEB MAR 'APR . "MAY. , JUN P JUL' AUG; ;SE OCT. .NOV DEC" A. How many total visitors,attendees,travelers,campers,patients 300 300 300 750 1000 1200 1400 1400 1200 900 300 250 or customers have access to the water system each month? B. How many days per month is water accessible to the public? 31 28 31 30 31 30 31 31 30 31 30 31 32. REGULAR NON-RESIDENTIAL JAN MAR JUN JUL AUG SEP OCT'- NOV USERS FEB APR MAY DEC,.;- - A. If you have schools,daycares,or businesses connected to your water system,how many students,daycare children and/or 12 12 12 15 20 20 20 20 15 12 12 12 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 1 1 1 1 1 1 1 1 1 1 1 1 34 NITRATE SCHEDULE '' QUARTERLY.. ,'' '..: ;:— •.ANNUALLY"' ONCE EVERY 9 YEARS (One Sample per source by time period) 35 Reason forSubmitting WFI: 0 Update-Change 0 Update-No Change ❑Inactivate ❑Re-Activate 0 Name Change 0 New System 0 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: DOH 331-011 (12/2025) DOH Copy Page: 2 WS ID WS Name 51920 UNION Total WFI Printed: 1 DOH 331-011 (12/2025) DOH Copy Page: 3 1111 Division of Environmental Washington 5tate nubile of Water Facilities Inventory(WFI) Report Create Date: 3/16/2026 Water System Id(s): 51920 Print Data on Distribution Page: ALL Print Copies For: DOH Copy Water System Name: ALL County: --Any-- Region: ALL Group: ALL Type: ALL Permit Renewal Quarter: ALL Water System Is New: ALL Water System Status: ALL Water Status Date From: ALL To ALL Water System Update Date ALL To ALL Owner Number: ALL SMA Number: ALL SMA Name: ALL Active Connection Count From: ALL To: ALL Approved Connection Count ALL To: ALL Full-Time Population From: ALL To: ALL Water System Expanding ALL Source Type: ALL Source Use: ALL WFI Printed For: On-Demand DOH 331-011 (12/2025) DOH Copy Page: 2