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Home My WebLink AboutWAT2026-00089 - WAT Application - 5/7/2026 WAT 2026 -00089 415 N.6'l'Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Belfairs 360-275-4467,Ext.4110 Building,Planning Environmental Health CommunityHealth E1ma:360-482-5269,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 an this application Part 1: Applicant/ Parcel Identification Name on Applicant: JRW' S �> Date: ta f�oZ'c Mailing Address: �� ' � ►tC`w°° d`�l• Phone: 5-�v � rota ` I7.� Parcel Number: J 2 Z l 7 —4`l -OO ra O 3 Type of Water System Reason for Application 1 Public/Community Water System(2 or more Building permit BLD2026-00310 connections) O Division of land: o Individual water source(one connection), #of Parcels? SPI_ 0 Well O Boundary line adjustment ❑ Spring/surface water ❑ 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: ` ' C ',L heLiuiid V Water Facility Inventory(WFI)Number: (write"none"for two-party) I am the manager of this water system.The water system has been a roved for q76 services. There are presently {`` connection(s)in use.This will be the connection. O I em 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 provid er to is ese)connection(s)without exceeding the limits of the water system or any limits s bf to and ,cal regulation. Signature of Water System Manager t - Date ✓„' r C "� This form may be scanned and available for public view at www.co.mason.wa.us. J:1EH Fonns\Drinking Waiter Revised 4/412018 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). EH APPROVED Reviewer'8 Signatures: Environ. Health: Anderson 05/07/2026 Date 5/7/2026 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 WATER FACILITIES INVENTORY (WFI) Quarter: 1 FORM Updated: 03/26/2025 Printed: 5/7/2026 ONE FORM PER SYSTEM WFI Printed For: On-Demand m 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 GROUP 3 TYPE 45090 R LAKELAND VILLAGE WATER MASON 'A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7 OWNER NAME&MAILING ADDRESS .....A v..a. w RICHARD A.ANDERSON[MANAGER] LAKELAND VILLAGE WATER CO OWNER CONTACT PO BOX 108 RICHARD A.ANDERSON ALLYN,WA 98524 PO BOX 108 ALLYN,WA 98524 STREET A1 DRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM"ROVE ATTN ATTN ADDRESS 470 E COUNTRY CLUB DR ADDRESS CITY ALLYN STATE WA ZIP 98524 CITY STATE ZIP 9,24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER'CONTACT INFORMATION Primary Contact Daytime Phone: (360)275-2474 Owner Daytime Phone: (360)275-2474 Primary Contact Mobile/Cell Phone: (360)801-0630 Owner Mobile/Cell Phone: (360)801-0351 Primary Contact Evening Phone: Owner Evening Phone: Fax: (360)275-0266 E-mail: Lakelandll@msn.com Fax: E-mail: Lakeland11@msn.com Ti.SATELLITE MANAGEMENT AGENCY SMA(check only oney Not applicable(Skip to#12) 0 Owned and Managed SMA NAME: SMA Numbero ' . Managed Only Owned Only 12 WATER SYSTEM CHARACTERISTICS(mark all that apply) Q Agricultural 0 Hospital/Clinic XResidential Commercial/Business D Industrial (School i]Day Care Licensed Residential Facility OTemporary Farm Worker X Food Service/Food Permit 0 Lodging DOther(church,fire station,etc.): ., 1,000 or more person event for 2 or more days per year fl Recreational/RV Park Q RTCR Seasonal System 3 WATER SYSTEM OWNERSHIP(mark only one)- 4. STORAGE CAPACITY(gallons) Association 0 County M Investor D Special District 0 City/Town Q Federal D Private D State 240,000 -SEE NEXT PAGE FOR A COMPLETE LIST OF SOURCES- DOH 331-011 (12/2025) DOH Copy Page: WATER FACILITIES INVENTORY (WFI) FORM - Continued i, SYSTEM ICS NO. a SYSTEM NAME 3,"COUNTY:` 4 GROUP 5 TYPE 4500 R ' + LAKELAND VILLAGE WATER MASON 15 16. 17 x, 8 18 20 21 ag 23 24 SOURCE NAME x INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION' @ F LIST UTILITY S NAME FOR SOURCE Gxi w '>m O s " AND WELLTAG ID NUMBER y -+ n • Example WELL#'F XYZ466 m � r- n c G u �-n.. m p O .�� O a ? S► ,' gyp.. p x -t"" O IF SOURCE iS hURCMASED_OR INTERTIE r ` ti 47 i� yy ,� zz v O C z r . m ro ,,< » ' . 'O. is . a z - C7..' x. A z SYSTEM D D =r z o mm x -� a c r ya INTEATIED, LIST SELI Ent NAME;.: m, zz z m a O ap z r :m" Z m ,a -�°.,. x aG, ple: SEATTLE" i NUMBOR r G O 0 D O "A" A, [ .a -�. r. < "C7; m z . Z S, , rn z o G a m 501 WELL#1 No tag X X N X 407 40 SE NE 19 22N 01W S02 WELL#2 AFK552 X X Y X 294 155 SW SE 17 22N 01W S03" WELL#3 AFK553 X X Y X 205 250 SW NE 20 22N 01W SO4' WELL#4 AHA980 X X Y X 211 400 SE NW 20 22N 01W SOS WELL#5 AFK551 X X Y X 105 140 NE SW 17 22N 01W S06 WELL#6 AKM942 X X Y X 406 400 NW NW 20 22N 01W DOH 331-011 (12/2025) DOH Copy Page: 2 WATER FACILITIES INVENTORY (WFI) FORM - Continued 4. SYSTEM ID NO. " 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE " 45090 R LAKELAND VILLAGE WATER MASON A Comm DOH USE ONLY! 011 USE ONLY ACTIVE- 'CALCULATED" ,APPROVED . SERVICE "ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 898 975 A. Full Time Single Family Residences(Occupied 180 days or more per year) 793 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 40 B. Full Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied more than 180 days/year 105 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/ovemight units) 0 0 0 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 20 .20 0 28. TOTAL SERVICE CONNECTIONS . 918 975 29.FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 2023 30. PART-TIMERESIDENTIAL POPULATION, JAN FEB MAR APR. MAY 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, MAR APR MAY JUN JUL: AUG FEB, SEP OCT'- NOV DEC A. How many total visitors,attendees,travelers,campers,patients 88 148 267 529 870 934 1594 1438 973 384 94 59 or customers have access to the water system each month? B. How many days per month is water accessible to the public? 20 20 20 20 20 20 20 20 20 20 20 20 - - - .. - - -.- -.- - 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 17 17 17 17 17 17 17 17 17 17 17 17 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 2 2 2 2 2 2 2 2 2 2 2 2 34. NITRATE SCHEDULE" !. QUARTERLY a ANNUALLY:.::, ONCE EVERY 3 YEARS (One Sample per source by time period) _._.. -35 Reason for Submitting WFI ❑Update-Change ❑ Update-No Change ❑Inactivates ❑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 45090 LAKELAND VILLAGE WATER Total WFI Printed: 1 DOH 331-011 (12/2025) DOH Copy Page: 5 WashIngton State Department of HEALTH Water Facilities Inventory(WFI) Report Create Date: 5/7/2026 Water System Id(s): 45090 Print Data on Distribution Page: Yes 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: Act 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