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HomeMy WebLinkAboutWAT2026-00170 - WAT Application - 8/5/2026 415 N.G°Sheet MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Sheue¢360-429.9660,Cxt.400 Belfeh:360-275.4467,8xt.400 Wpd,nq,mmnmp.Enwon,nmtelxnxncnmm„mlyx„l,M1 Elms:360-482-5269,Ext.400 Application for Determination of Water Adequacy Instructions 1. Complete Part I. Na determInation2 can in to h typet 1 Partthe 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 on Applicant: Daniel Cusick Date: 04/24/2024 Mailing Address: PO Box 1019, Wauna, WA 98395 Phone: 253-358-9859 Parcel Number: 42216-53-000.10 Division-block-lot: 16-10 Type of Water System Reason for Application_q�� 1 RI Public/Community Water System(2 or more © Building permit SLO O b�10q ox 4Y I connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels?________ SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) EliOther(explain) ❑ Replacement or Remodel(please indicate name if you have more than one residence connected of water system below if applicable—no to this well, chock the Pub)ic/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: LAKE CUSHMAN SYSTEM 5 Water Facility Inventory(WFI)Number; 035290 (write"none"for two-party) [] am the manager of this water system.The water system has been approved tor'/1 gervices, There are presently connection(s)in use.This will be the__connection. 91 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: Connect to one Bedroom Park Model Home 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 JESSE MATHEWS Phone 360-877.9@66 7E F(V06E1NC Signature of Water System Manage =_ „„w.,.,=,^ ==w0 Date 04/25/2024 This form may be scanned and available for public view at www.co.nlason.wa.us. 1:\011 norms\odnllng Waler NevIsed 4/21/2021 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 flp://nis.co.n1asoI1wa us/planning 14,_15_16 22 Water use or limitation recorded...._............................. N/A_Yes_ WellDrilled ............................................................. Date Individual Spring/Surface Water ❑ WDOE permit(attach to application) Cl 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) _ N Satisfactory Determination: WAT2026-00170 This determination does not address adequacy of the dlstdbution 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.T0A 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). I-El AP[I(O\ II) eviewor's Signatures: . )S I! Date 8/5/2026 Environ. Health: _ This form may be scanned and available for public view at www.co.masOfl,Wa.US. Page 2orz 2024-04-18 CUSICK 16-10 Application for Determination of Water Adequacy Final Audit Report 2024-04-26 Created 2024-04-18 By: Chevon Brownell(chrowneii©Iakecushmonmacom) Status'. Signed Transaction ID: CBJCHBCMBMCRGOORCWJYXudXCIIYTINGIWTBF95Uh "2024-04-18 CUSICK 16-10 Application for Determination of Wat er Adequacy" History y,] Document created by Chevon Brownell(cbrownell@lakecushmanmc.com) 202404-18-4:00:30 PM GMT-IP address:206.214.54.14 C Document emalled to DANIEL CUSICK(dancusick@yahoo.com)for signature 2024-04-18-4:02:22 PM GMT i61_l Email viewed by DANIEL CUSICK(dancusick@yahoo.com) 2024-04-24.10:04:44 PM GMT-IP address:6740.1 5.27 he Document e-signed by DANIEL CUSICK(dancusick@yahoo.com) Signature Date:2024-0424-10:16:42 PM GMT-Time Source server-IP address:6740.1527 Gr Document emalled to JESSE MATHEWS omathews@lakecushmanmc.com)for signature 2024-04-24-10:10 44 PM GMT In Email viewed by JESSE MATHEWS(jmothews@lakecushmanmc.com) 2024-04-25-2:50:04 PM GMT-IP address:206.214 59.108 hr. Document e-signed by JESSE MATHEWS (mathows@lakecushmanmc.com) Signature Date:2024.04-25-2:59:22 PM GMT-Time Source:server-I P address:206.214.59.198 ER- Document emalled to Chevon Brownell(cbrownell@lakecushinanmc.com)for signature 2024-04-25-2:59:2a PM Dos r Email viewed by Chevon Brownell(cbrownell@lakecushmanmc.00m) 2024-04-26-4:39:10 PM GMT de Document e-signed by Chevon Brownell (cbrownell@lakecushmanme.com) Signature Date:2024-04-26-4:39:28 PM GMT-Time Source'.server Adobe Acrobat Sign Signature: ^w avw.a Email: cbrownell@lakecushmdnmc.com Agreement completed. 2024-04-26-4'8920 PM GMT Adobe Acrobat Sign WATER FACILITIES INVENTORY (WFI) paaler 11/042025 . , FORM Printed: 8/5/2026 ONE FORM PER SYSTEM WFI Printed For: On-Demand H E Q 8.l"H Submission Reason: Pop/Connect Update RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA 98504-7822oremailwfi@doh wa.gov 1. SYSTEMM}NO. 2. SYSTEM NAME. 5. COUNTY 4 GROUP 5. TYPE Q35O LAKE CUSHMAN SYSTEMS MASON A Cbmm e.PRIMARY CONrACT NAME B MAILING ADDRESS 7.OWNER NAME B MAILING ADDRESS CHEVON A. BROWNELL LAKE CUSHMAN MAINTENANCE CO. PRESIDENT,JUNE 2O23- 3740 N.LAKE CUSHMAN RD. ELIZABETH STEPHENS HOODSPORT,WA 98548 3740 N. LAKE CUSHMAN RD. HOODSPORT,WA 98548 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP F PRIMARY CONTACT INFORMATION 10.OWNERCONTACT INFORMATIONact Daytime Phone: (360)877-2728 Owner Daytime Phone'. (360)877-9668tact Mobile/Cell Phone'. (912)227-6426 Owner Mobile/Cell Phone_tact Evening Phone: (360)490-6549 Owner Evening PhoneE-mail: CxxxxxxxL@LAKECUSHMANMC.COMFax E-mail: bxxxxxxxs@lakecushmanmc comTE MANAGEMT AGENCY-SMA(check only one) ot applicable(Skip to#12)wned and Managed SMA NAME SMANumberManaged Only Owned Only 12 WATER SYSTEM CHMACTERIS'ncs(nSc al ttS 8 ❑ Agricultural ❑ Hosptal/Clme OResldenbal Commercial I Business ❑ Industrial ❑school ❑ Day Care ❑ Licensed Residential Facility ❑Temporary Farm Worker ❑ Food Service/Food Permit ❑ Lodging QOther(church.fire station,etc.): 1 000 or more person event for 2 or mare days per year Recreational/RV Park ❑RTCR Seasonal Svstem ;.WA1fl SYSTaOWNERSHIP( rt... oM°One) . STORAGE CAPACtTVaUune) ❑Association p County ❑Investor ❑speoal District❑City /Town ❑Federal Privale ❑State 579.300 - SEE NEXT PAGE FOR A COMPLETE LIST OF SOURCES WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 035290 LAKE Ct15HMAN SYSTEM 5 MASON A CPRPn 15 18 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION w ny= ~ D LIST 'S NAME FOR SOURCE FrA x v °i ANOWENOWELLTAGP]NUMSER i Z p m j a w D w gm a EssmPle: WELL At%Y2458 y w m w P 5 Drm a� w 2 S IFSWRCET RTIED SEO OR (SYSTEM v O £ £ O m m 2 S� D i O i*O i O w INTERR'S SYSTEM m p m D y `iI S m 2 A 0 'a 0 mm y= O m x w LIST SELLER'S NAME ID L s Q x P a m g EvamPN: SEATTLE HUMBER r i] o w v z z a y rD' o m i i i mP �x mw SOI WELL#3 AH86770-5 Shop X X V % 35 165 NW NE 29 23N 04W $02 WELL#5 AHB6]B D-14 Park X X v % 55 178 SW NE 05 22N 04W 504 WELL#8 AHS679 D-14 Park X % V X 93 165 SW NE 05 22N 04W $0$ WELL#7 AHB6]5 0-6 1st Hole GC X X V X 40 60 SE SW 04 22N 04W X X V X 90 96 NE NW 09 22N 04W $43 WELL#11 AHB676 0-7 2nd Hole GC WT WELL#4D-9Park X X V X 18 80 SWNE 16 22N 04W SOS 301 WELLp10352]YiLPKE GUSH#1 X X V X 145 NE NE 29 23N 04W X y X 192 110 NW NE 29 23N 04W SW 502 WELL#903527V/LAKE GUSH b1 XI I WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5.TYPE 035290.. LAKE CUSHMAN SYSTEMS MASON A Comm UGH USE ONLYI OH USE ONLY ACTIVE CALCULATED: APPROVED SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 1614 Unspecified A. Full Time Single Family Residences(Occupied 180 days or more per year) 646 B. Pan Time Single Family Residences(Occupied less than 180 days per year) 968 26. MULT1PAMILY RESIDENTIAL BUILDINGS(How many of the following de 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 100 days/year 0 27. NON-RESIDENTIAL CONNECTIONS(How many of Me following do you havaT) A.Recreational services and/or Transient Accommodations(Campsites,RV sites.M1olellmoteuevernioht units) 0 0 B. Institutional,GommercallBusnes5.School.Day Care.Industrial Services, to 16 16 26. TOTAL SERVICE CONNECTIONS 11330 2 . FULLTIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 1605 30. PART-TIME RESIDENTIAL POPULATION JAN FEB MAR APR MAY JUN JUL AUG SEF OCT NOV DEC A. How many part-time residents are present each month? 2420 2420 2420 2420 2420 2420 2420 2420 2420 2420 2420 2420 B. I low many days per month are they present? 8 a 8 15 25 25 25 25 15 S 8 8 31.TEMPORARY&TRANSIENT USERS MIFESMAR APR MAY JUN JUL AUG SEP OCT NOV DEC A How M1ave access to the all vste e system des. rpical, campers, patient' 206 620 1240 1200 1240 1240 620 206 40 40orc m ech month' B. How many days per month is water accessble to the public? 31 30 31 30 31 31 30 31 30 31 32. REGULAR NON-RESIDENTIAL USERS JAN FEB MAR APR MAY JAIN 6 JUL ;AUG SEP OCT NOV DEC A II you have schools,daycares,or businesses connected to your water system,how many stdets and/or I 13 13 13 13 13 13 13 13 13 13 13 13 present u n employees are that are NOT already included n the residential population? B. How many days per moron are they present? 21 21 21 21 21 21 21 21 21 21 21 21 33. ROUTINE COLIFORM SCHEDULE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 2 2 2 3 4 4 4 4 3 2 2 2 34 NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY 3 YEARS (One Sample per source by time period) 35.Reason for SubmMlrp WFI: ❑Update-Change ❑ Update-No Change ❑Inactivate ❑Re-Activate ❑ Name Change ❑New System ❑Other 36. I certify that the information stated on this WFI torm is correct to the best of my knowledge. SIGNATURE: DATE: PRINT NAME: TITLE: Intentionally left blank WS ID WS Name 03529 LAKE CUSHMAN SYSTEM 5 Total WFI Printed: 1 F a rt <. x w,:nmuv,.. ... o..o.........yor Water Facilities Inventory(WFI) Report Create Date: 8/5/2026 Water System Id(s): 03529 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