The URL can be used to link to this page

Home My WebLink AboutWAT2026-00096 - WAT Application - 6/5/2026 WAT 2026 - 00096 MASON COUNTY UthW COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health 415 N 6th Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 •S Belfalr:(360)275-4467 ext 400 ❖ Elma:(360)482-5269 ext 400 FAX(360)427-7787 Application for Determination of Water Adequacy Instructions 7 Complete Part. No determination can be made until.Part I 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 buildin site. lan mustaccom any this application. . .. _ Part 1: Applicant/ Parcel Identification Name on Applicant: ']t ? fL!'� > Date: JJ Mailing Address: f 7 ?I,r.h0 t/ cs Phone: Parcel Number: 2LO77— � r Spy h, Type of Water System Reason for Application Public/Community Water System (2 or more i7 Building permit BLD2026-00419 connections) ❑ Division of land: 0 Individual water source(one connection), #of Parcels? SPL ❑ Well O Boundary line adjustment ❑ Spring/surface water O Other(explain) O 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: f� �/��i/�T��ii 60,4? it*'1,4 ,'t1 iS Water Facility Inventory(WFI) Number: 093- 70 (write"none"for two-party) lam the manager of this water system.The water system has been approved for/2-V services. There are presently !260 connection(s) in use.This will be the_ __connection. ❑ 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 tate and local regulation. Sgi na ure of Water System.Mana er Date y' �� tManager___________________________ 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(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http•//gis.co.mason.wa.us/planning 14.15,_16_22_ Water use or limitation recorded................................... N/A_____N/A Yes WellDrilled ............................................................... Date 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) fffi ;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 WIQE 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. 11 Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of Its Intended use for the following reasons),.. EH APPROVED Reviewer's Signatures: Environ. Nealth:, La.Anderson 06/05/2026 Date :6/5/2026 WATER FACILITIES INVENTORY (WFI) Quarter: 1 Updated: 02/05/2026 FORM Printed: 6/5/2026 ONE FORM PER SYSTEM 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. COUNTY .._ ._. 4 GROUP S. TYPE 88370 Y TIMBERLAKE COMMUNITY CLUB INC MASON A Comm 6 PRIMARY CONTACT NAME&MAILING ADDRESS; 7.OWNER NAME,&`MAILING ADDRESS MARCUS L.VIND[OPERATOR] TIMBERLAKE COMMUNITY CLUB INC PRESIDENT 2880 E TIMBERLAKE DR W RUSSEL POPPENROTH SHELTON,WA 98584 2880 E TIMBERLAKE DR W SHELTON,WA 98584 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP 9.24 YOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)427-8928 Owner Daytime Phone: (360)930-2605 Primary Contact Mobile/Cell Phone: (507)822-4684 Owner Mobile/Cell Phone: (360)930-2605 Primary Contact Evening Phone: (360)463-0664 Owner Evening Phone: (xxx)-xxx-xxxx Fax: E-mail: wxxxxxxxxxxr@timberlakecc.com Fax: (360)427-1755 E-mail: pxxxxxxxt@timberlakecc.com 1 SATELLITE MANAGEMENT AGENCY•SMA(check only ones Not applicable(Skip to#12) O Owned and Managed SMA NAME: SMA NumberEl : Managed Only . Owned Only ;12.WATER SYSTEM CHARACTERISTICS{mark all that apply) O Agricultural 0 Hospital/Clinic ]g[Residential El Commercial/Business El Industrial OSchool o Day Care O Licensed Residential Facility OTemporary Farm Worker Food Service/Food Permit 0 Lodging DOther(church,fire station,etc.): 1,000 or more person event for 2 or more days per year Recreational/RV Park El RTCR Seasonal System 3..WATER SYSTEM OWNERSHIP(mark only one) It4. STORAGE,CAPACITY(gallon )KAssociation 0 County XN Y O Investor N p� El Special District El City/Town Ii Federal Ei Private ❑State 260,000 15 16 . `- 1 18 19. 20 21 22 23 a 24 ' ; SOURCE INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION,; LIST UTILITY'S NAME FOR SOURCE rr- N m a D m AND WELL TAG ID NUMBERS -. ,n " n ;V - Example; WELL#I XY2456 z v in ' c a O v a, X o c� -n rn m _ O ia. F r M > m' c> �. m s. _ 'q 22 a r•rn. �O 6y, z o IF SOURCE IS PURCHASED OR INTERTIE r Q r N Z G) a 4 Q 1 m INTERTIED, SYSTEM' In "n '� �' D D r_ -i z O m m 'Y' -rt O x Zr O LIST SELLER'S NAME r- r .r Exarrtple :SEATTLE NUMBER r `3 v c? o `o $01 WELL#1 ABR116 8" X X Y X X 342 180 NW SE 18 20N 02W 502'WELL#2 AFK577 8" X X Y X X 280 250 NW SE 18 20N 02W 803 WELL#3 AEC923 X X Y X X 373 280 NW SE 18 20N 02W S04 WF(SI,S02,S03) X X Y X 280 710 NW SE 18 20N 02W WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO.., 2: SYSTEM NAME 3 COUNTY 4 "GROUP 5 TYPE 88370 TIMBE RLAKE COMMUNITY CLUB INC MASON A Comm DOH USE ONLYI ACTIVE' CALCULATED O A H USE ONLY SERVICE'.=, ACTIVE API?F�OUED , CO CONNECTIONS CONNECTIONS CONNECT 25.'SINGLE FAMILY RESIDENCES(Haw many of the following do you have?) 968 Unspeclfie A. Full Time Single Family Residences(Occupied 180 days or more per year) 668 B. Part Time Single Family Residences(Occupied less than 180 days per year) 300 26. MULTIFAMILY 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. 90 90, - 28:TOTAL SERVICE CONNECTIONS 1058 29:-FULL-TIME RESIDENTIAL POPULATION ; A. How many residents are served by this system 180 or more days per year? 1400 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? 200 200 250 300 400 600 800 900 400 300 250 200 B. How many days per month are they present? 31 28 31 30 30 30 31 31 30 31 30 31 31. TEMPORARY&TRANSIENTUSER5 UG SEP'JAN FEB MAR. -APR MAY;, JUN" ' JULJllL OCT •°NOV. DEC; A. How many total visitors,attendees,travelers,campers,patients 100 100 100 300 400 700 700 800 500 300 200 200 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 30 30 30 30 30 30 30 31 32. REGULAR NON-RESIDENTIAL USERS JAN; FEB . :MAR APR MAY 'JllN, ; JUL - AUG 'SEP OCT. NO1r DEC A. If you have schools,daycares,or businesses connected to your water system,how many students,daycare children and/or 10 10 10 10 10 10 10 10 10 10 10 10 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 AtJaa. SEP OCT NOV DEC,,, 2 2 2 2 2 2 2 2 2 2 2 2 34. NITRATE SCHEDULE QUARTERLY , =ANNUALLY ONCE EVERY 3 YEARS, (One Sample per source by time period) f sr y.-- 1 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: WS ID WS Name 88370 TIMBERLAKE COMMUNITY CLUB INC Total WFI Printed: 1 n of Envlronmntsl Publlc Hnaltb Washington State Department of HEALTH Water Facilities Inventory(WFI) Report Create Date: 6/5/2026 Water System Id(s): 88370 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 11/111 nn. nI4 /in/nnn C �„i'r. O