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Home My WebLink AboutWAT2026-00064 - WAT Application - 4/17/2026 2026 - 00064 15 d €'n tr r Shelton,WA 98S4 hrttons,160427 9£,70,Ext 400 Public Health & Human Services ttel or544t,t,EXt,400 Application for Determination of Water Adequacy Instructions s Complete Part 1. Edo determination ran be marfe until Fart 2 is fulty completed.. 2. Complete only the portion of Part 2 applying to the type of water connection utilized. Submit completed application with any required attachments for review. 4, An a rimed tau in site Ian must accom do this licatwn. Part 1; Applicant! Parcel Identification Name of Applicant: s ° r o Rater to Marling Address: / Phone; Parcel NumbecL 7 Type of Water System Reason for Application Public/Community Water System(2 or more , ' Building permit BLD2026-00268 connections) 0 Division of land: 0 Individual water source(one connection), #of Parcels? SPL O well 0 Boundary line adjustment O Spring/surface water o Other(explain) 0 Other(explain) O Replacement or Remodel(please indicate name II you have more than one residence connected of water system below if applicable- no to this well,check the PubliclCommunity Water signature required) .System box. Pert 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: t t Water Facility Inventory(WFI)Number: Q4 9 (write"none"for two-party) 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 LI connection. 0 1 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)connections)without exceeding the limits of the water system or any limits set by state and local regulation. Print lame of Water System Manager 4/ / Phone Signature of Water System tanager ' This form may be scanned and available for public view at www.mason ountywa.gov iiy' ft I rux, t rtnting With R vl ed ot1o�ar'2f24 r D€2 Group B Water Systems Satisfactory taccteriological test within last year(attach to application). 01/14/2026 Individual Water Well 0 Water well report(attached to application). Depth ft. 0 Well capacity Test(attached to application) __gpm gpda 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 it 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 SpringlSurface Water 0 WDOE permit(attach to application) Q Method of disinfection Cf 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 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 36.7OA RCW. O 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: Environ, Health,: •Anderson 04/17/2026 Date 04/17/2026 This form may be scanned and available for public view at www.masoncountywa.aov £'rtgo 2 of 2 5e4 n urstt)f1COOIJIltyI'nvirr,Irnnrcntal Fla4lih . Olynal,lsa,WA 1Th5u6 J(iO His/ )t.II jirna #mom r' COLIFORM BACTERIA ANALYSIS ..._ - rnlmty f'ar ;ta a l l l aollccicd line,Nlnl1alo Colleelnd �} } M1l m vpa of/,t Sri S)>tLna(,hock only one box) car Private Household 0 Group A Group B ❑Other— I -roue A aand Group B Systems—Provide from Water Facilities Inventory(WFI): System Name: Contact Person' t ' (j ��, Day Phone:i3 }) `' �2ty ; Eve.Phone:( ) Send results lo:(Print full name,address and rip code or email address) I II .....�'Cxl �.(� ". ^t v .-........_...._.�...__............._._..__... o n Ei 1�1r.WC S SAMPLE INFORMATION Sample collected by(name): Specific location or address where sample collected: Special instructions or comments: Type of Sample(must check only one box of#1 through#4 fisted below) 1.❑RoutineDistiibution Sample 2.Repeat Sample(after unsat,routine) Chlorinated:Yes_No_ ❑Distribution System Chlorine Residual:Total_Free_ Chlorinated:Yes_No,__ 3,Raw Water Source Sample Chlorine Residual:Total_Free ❑E.coil—GWR(AIP) ❑Fecal—solace,Owl,springs(numoralion) Unsatisfactory routine lab number: Filtered:Yes_No_ ❑Assessment Monitoring(AIP) Unsatisfactory routine collect date: ❑0ther 1 I S 4.NSample Collected for Information Only Investigative` Construction I Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and ,Satisfactory ❑E.coli present ❑Ecoli absent No Coliform detected Rap ccement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ �BarlefialDeVrSiV Results:Total Coliform t100m1. _ E.coti I 100na1. Fecal Csllrorm _ _J100ml Enterococci 1100 nai, t`4ethoo Code: SM 92236 ❑SM 9222D — t Date aL-7 7CO Sfd 92ISB ❑Enteralere ' yDate .GOC. WATER FACILITIES INVENTORY (WFI) Quarter: 0 if Updated: 01/23/1998 FORM Printed: 4/17/2026 ONE FORM PER SYSTEM WFI Printed For: On-Demand ... Submission Reason: Non-Periodic 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 COUNTY 4."GROUP 5TYPE , 04906 0 AMICK,ED MASON 6 PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS .... ED AMICK[OWNER] ED AMICK E 397 ALTA DRIVE E 391 ALTA DRIVE BELFAIR,WA 98528 BELFAIR,WA 98528 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP 9.24HOUR PRIMARY CONTACT INFORMATION 10.OWNER`'CONTACT INFORMATION Primary Contact Daytime Phone: (360)275-2808 Owner Daytime Phone: (222)333-4444 Primary Contact Mobile/Cell Phone: Owner Mobile/Cell Phone: Primary Contact Evening Phone: Owner Evening Phone: Fax: E-mail: Fax: E-mail: 1 SATELLITE MANAGEMENT AGENCY SMA(check nnly one) ,ww ,,. ... Not applicable(Skip to#12) 0 Owned and Managed SMA NAME: SMA Number 0.. Managed Only Owned Only 2 WATER SYSTEM,CHARAGTERISTlCS'mark ail that apply) �._ _. ... ..._ __ .'_ Agricultural Hospital/Clinic XResidential 0 Commercial/Business 0 Industrial E]School 0 Day Care 0 Licensed Residential Facility OTemporary Farm Worker l] Food Service/Food Permit 0 Lodging pother(church,fire station,etc.): 1,000 or more person event for 2 or more days per year D Recreational/RV Park 0 RTCR Seasonal System 3.WATER SYSTEM OWNERSHIP(mark only on 4 STORAGE CAPACITY(gallons) Association QCounty Investor o Special District City/Town p Federal Private p State 15 16 .: 17 18 19 20 21 22. 23 24 " SOURCE NAME 1• INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION.`; M A '. LIST UTILITY'S NAME FOR SOURCE ,,; z ",. Z _ us AND WELL TAG NUMBER — 2 �' O m m N , ... z �. A 'ti A C)j Example "WELL.#1 XYZ456 ro z m O �n Vi z IF SOURCE IS PURCHASED OR INTERTIE 'r rn G1 e7 g O " N "Q 'r' z a O 0, _Z-� rD m C INTERTIED,.. SYSTEM n' n ° ^_n z D D r --� z O m m, z D D z 1 rn O z n z: ss `LISTSELLER'S NAME ID r� m .m `0 m; m -� -a m x m z z . O =t �€ 0 ,3 m c O -i 07 yam+;,, z r r :r z r r m rn m z D Q Fn Example: &1 ATTLE NUMBER r o- o A o o -t A -f r C o m z z z S z cn z 4 ""q`" " m S01'WELL#1 X X X 260 27 SE SW 05 22N 01W DOH 331-011 (12/2025) DOH Copy Page: WATER FACILITIES INVENTORY (WFI) FORM - Continued 1 SYSTEM ID NO. 2 SYSTEM NAME' 3 COUNTY 4 GROUP 5 TYPE' AMICK,ED MASON LY!QOH USE ONOH USE ONLY ACTIVE CALCULATED" APRROVED . SERVICE .:"'� ACTIVECONNECTONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 4 Undetermined A. Full Time Single Family Residences(Occupied 180 days or more per year) 4 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 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 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 0 0. 28."TOTAL SERVICE CONNECTIONS 4' 29. FULL-TIME RESIDENTIAL POPULATION ........-,,. ., _... __...- . ..........._..M..-. __... A. How many residents are served by this system 180 or more days per year? 16 311.PART-TIME RESIDENTIAL POPULATION JAN FEB MAR APR-" _eMAY 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 r OCT' NOV 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. If you have schools,daycares,or businesses connected to your water system,how many students,daycare children and/or employees are present each month that are NOT already included in the residential population? B. How many days per month are they present? 33. ROUTINE COLIFORM SCHEDULE JAN FEB MAR. APR MAY JUN JUL AUG SEP OCT- NOV DEC 34NITRATE SCHEDULE '+ QUARTERLY ANNUALLY; ONCE EVERY 3 YEARS (One Sample per source by time period) _- . 35. Reason for Submitting WFI: ' ❑Update-Change ❑ Update-No Change ❑Inactivate ❑Re-Activate ❑ Name Change ❑New System ❑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 04905 AMICK, ED Total WFI Printed: 1 DOH 331-011 (12/2025) DOH Copy Page: 3 Washington State Department of Water Facilities Inventory(WFI) Report Create Date: 4/17/2026 Water System Id(s): 04905 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