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Home My WebLink AboutWAT2026-00071 - WAT Application - 4/1/2026 U, WAT — UO ' s?- `' =v ` ^Ya s.` 415 N.6111 Sheet �' �� O ,� F �Y �� ,. � sheil�,�, �vA�sss•I uu hhc Health 81. Human Ser�,rices Shelton;350-4279670,EEx t.400 s;z , t3elfair:360-27755-4 4G7,Ezt.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.—4 Ana proved building site plan must accompany this application. Part 1: Applicant/ Parcel Identification �Name of Applicant: j2a nat, 0 1k Date: L I2t, MailingAddress: ,-_ ;-� 3(O e . Gt<1ctA ne: s q Parcel Number: = 2-( 2 7S0000 c2) 5 Type of Water System Reason for Application "Public/Community Water System(2 or more I( Building permit } �1 ° connections) r 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 Pudic/Community'Water signature required) System box. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: TT L Public Water System Name of Water System: L.�.,I e- 11,'n' ,r �-f-\ E.!.)Ct(e.r 5V 5—e✓v, Water Facility Inventory(WFI) Number: ggi S"0 t (write"none"for two-party) 1'l services.There I am the manager of this water system.The water system has been approved for 13 are presently ?f `�S. 01 connection(s)in use.This will be the r,7_c?) connection. O 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)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 d Iv) ii Phone St' ,Signature of Water System Manager ( 2 L -/LL/ LLA Date .7-.t This form may be scanned and available for public view at www.masoncountywa.gov J:1EH Forms\Drinking Water Revised 05/0812024 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) 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) 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 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). FH APPROVED Reviewer's Signatures: Anderson 04/20/2026 Date 04/20/2026 Environ. Health: This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER FACILITIES INVENTORY (WFI) Quarter: 1 Updated: 04/16/2025 ® FORM ® Printed: 4/20/2026 ONE FORM PER SYSTEM WFI Pr HE ALT H inted For: On-Demand Submission Reason: Contact 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 5 TYPE 44150 T - LAKE LIMERICK WATER MASON A Comm ";- 6 PRIMARY CONTACT NAME&MAILING ADDRESS 7 OWNER NAME&MAILING ADDRESS CHRISTOPHER M. MCMULLEN[OPERATOR] LAKE LIMERICK COUNTRY CLUB INC GENERAL MANAGER 790 E ST ANDREWS DR CHRISTOPHER M. MCMULLEN SHELTON,WA 98584 CHRIS MCMULLEN WTR DEPT 790 EAST ST.ANDREWS DRIVE SHELTON,WA 98584 STREET ADDRESS lF DIFIFEREN7 FI20M ABOVE, ;° STREET ADDRESS".IF,61FFERENT FROM 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)426-4563 Owner Daytime Phone: (360)426-3581 Primary Contact Mobile/Cell Phone: (360)580-5271 Owner Mobile/Cell Phone: (360)426-4563 Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone: Fax: E-mail: wxxxr@lakelimerick.com Fax: E-mail: wxxxr@lakelimerick.com 4.SATELLITE MANAGEMENT AGENCY-,SMA(check only one) Not applicable(Skip to#12) Owned and Managed SMA NAME: SMA Numberso Managed Only Owned Only 12 WATER SYSTEM CHARACTERISTICS(mark all that-apply) O Agricultural ❑ Hospital/Clinic )(Residential []Commercial/Business 0 Industrial 0School 0 Day Care 0 Licensed Residential Facility E]Temporary Farm Worker Food Service/Food Permit Q:Lodging $[Other(church,fire station,etc.): 1,000 or more person event for 2 or more days per year Recreational/RV Park Q RTCR Seasonal System 3 WATER SYSTEM OWNERSHIP(mark only one); ;;. 4 STORAGE gal ons); To CAPACITY 0 Association p County o Investor o Special District o City/Town Q Federal Private p State 320,000 -SEE NEXT PAGE FOR A COMPLETE LIST OF SOURCES- 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 44150"T' LAKE LIMERICK WATER MASON A `- Comm 15 16 17 18" 19 20 21 22 23 =24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT - DEPTH_ , SOURCE LOCATION m b-, LIST UTILITY S NAME 1=OR SOURCE z _ 0m AND WELL TAG ID NUMBER. z •cO [ 0 orn m ° Exampte WELL#1 XYZ456' v vi b n ° m �, v_ E n m O mv,� � .. O r O x a 1qr.. IF SOURCE IS PURCHASED OR INTERTIE P F, vi �- br O m ,a- m c INTERTIED, SYSTEM ^n n ° ++ rn D D c -t z O m m z x " a z a O z c- - o Z -� LIST SELLER rS NAME ID rrrz r x: maAcamz � O. cm momz ?� ,„ O ExmpleSATTLEs'. UNIBER r G O t7 C7A -c _r -coma z S . . ..cn 502- WELL#2 AHA978 X X Y X 103 200 NE NW 27 21 N 03W S03'.' WELL#3A AHA976 X X Y X 110 144 NW SW 27 21 N 03W 504 WELL#4 AHA973 X X Y X 92 74 SE SW 22 21N 03W 305 WELL#1 AHA974 X X Y X 89 49 NE NE 27 21N 03W S06 WELL#3B AHA975 X X Y X 167 194 SW SW 27 21N 03W 507, WELL#5 AHA977 X X Y X 110 35 NW SW 27 21 N 03W .508 WELL#6 ALH995 X X Y X 429 248 SE SW 27 21N 03W DOH 331-011 (12/2025) DOH Copy Page: 2 WATER FACILITIES INVENTORY (WFI) FORM - Continued 3:"COUN Y - 4 GROUP 5 TYP E 1 SYSTEM ID NO �2. SYSTEM NAME 441bp T � ,' LAKE LIMERICK WATER MASON A Comm . -L)OHUSEONLY1ACTOFf U5E`ONL`� SERVICE.CE m VE '.CALCULATE CO N E CT ONS CONNECTIONS CO PRgVED NNEE TIONS 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 844 Unspecified A. Full Time Single Family Residences(Occupied 180 days or more per year) 773 B. Part Time Single Family Residences(Occupied less than 180 days per year) 71 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) 354 354 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 3 3 26. TOTAL SERVICE CONNECTIONS}' 101°.' . 29 FULL-TIME RESIDENTIAL POPULATION A. How many reside ._ nts are served by this system 180 or more days per year? 1920 36.: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? 48 96 142 142 142 47 47 B. How many days per month are they present? 30 30 30 30 30 30 30 31 TEMPORARY,&;TRANSIENT USERS r. JAN -FEB MAR APR MAY. JUN JUL; AUG'; SEP OCT NOV DEC` A. How many total visitors,attendees,travelers,campers,patients 1200 1200 1200 1200 1600 1600 1600 1600 1200 1200 1200 1200 or customers have access to the water system each month? B. How many days per month is water accessible to the public? 30 30 30 30 30 30 30 30 30 30 30 30 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 21 28 29 30 34 33 34 29 29 26 27 22 employees are present each month that are NOT already included in the residential population? B. How many days per month are they present? 30 30 30 30 30 30 30 30 30 30 30 30 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 3a,NITRATE SCHEDULE QUARTERLY , , -, ANNUALLY,: •:ONCE EVERY.3 YEARS (One Sample per source by time period) 3$ 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: 3 Intentionally left blank DOH 331-011 (12/2025) DOH Copy Page: 4 WS ID WS Name 44150 LAKE LIMERICK WATER Total WFI Printed: I DOH 331-011 (12/2025) DOH Copy Page: 5 Washington State Department of HEALTH Water Facilities inventory(WFI) Report Create Date: 4/20/2026 Water System Id(s): 44150 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