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Home My WebLink AboutWAT2025-00046 - WAT Application - 3/25/2025 WAT AL; ) - Oi /1 %,—,. 415 N.6'h Street /� Shelton,WA 98584 ,,; ,\ MASON COUNTY Shelton:360-427-9670,Ext.400 q• 1 COMMUNITY SERVICES Belfair:360-275-4467,Ext.400 �v`/ Building.Planning.Enviionmenlal Health.Community Health Elma:360-482-5269,Ext.400 iPv�.� 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 this application. Part 1: Applicant/ Parcel Identification Name on Applicant: Royce Fisher Date: 02/20/2024 Mailing Address: 17010 State Hwy 106 Belfair, WA 98528 Phone: 360-545-7593 Parcel Number: 22211-50-00008 Type of Water System Reason for Application Public/Community Water System (2 or more Building permit '/(1 At5? -00 4 9 connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ Other(explain) 0 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: Sunset Beach Community Water Water Facility Inventory (WFI) Number: 86040N (write"none" for two-party) I am the manager of this water system. The water system has been approved for 99 services. There are presently 71 connection(s) in use. This will be the 72nd connection. 0 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 state and local regulation. Print Name of Water System Manager Melissa Cox on behalf of NWS Phone 360-876-0958 ext. 104 � (:,1• on behalf of NWS Date 02/20/2024 Signature of Water System Manager • I.� � �r1�t This form may be scanned and available for public view at www.co.mason.wa.us. Revised 4/27/2021 J:\EH Forms\Drinking Water 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/planninq 14 15_16__22_ Water use or limitation recorded . N/A Yes Well Drilled 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) At 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 re ions. Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determin a. Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. ha96 36.70A RCW. 41;e ® E Unsatisfactory Determination: 41 Applicant's water supply does not appear adequate to meet the needs of its intended use for tl �ywin>�iP�s i/ reason(s). 17, 1S Reviewer's Signatures: �k/g0� ,y� (I � Environ. Health: Date 3/ d 75 -,„,,.,47,,.. y This form may be scanned and available for public view at www.co.mason.wa.us. Page 2of2 WATER FACILITIES INVENTORY (WFI) Quarter: 2 Updated: 02/21/2025 0/� Washington State Department of FORM '�1#Health Printed: 3/25/2025 .; ,,,nrnralt,rntt4 ONE FORM PER SYSTEM L u,.,on OF L'n✓ry WFI Printed For: On-Demand off.of Dr,„k,nc Water 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 5. TYPE 86040 N SUNSET BEACH MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS KEVIN R. ODEGARD [OPERATIONS SUPV] SUNSET BEACH WATER ASSOC. INC. PRESIDENT PO BOX 123 GLENN LANDRAM PORT ORCHARD,WA 98366 PO BOX 123 PORT ORCHARD,WA 98366 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS 7245 BETHEL-BURLEY RD SE ADDRESS 53 E SUNSET BEACH DR 7.ITY PORT ORCHARD STATE WA ZIP 98367 CITY BELFAIR STATE WA ZIP 98528 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)876-0958 Owner Daytime Phone: (360)731-3260 Primary Contact Mobile/Cell Phone: (253)377-1865 Owner Mobile/Cell Phone: (360)731-3260 Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone: Fax: (360)876-4196 E-mail: Kxxxn@nwwatersystems.com Fax: IE-mail: gxxxxxxxxxxm@wavecable.com 1.SATELLITE MANAGEMENT AGENCY-SMA(check only one) D Not applicable(Skip to#12) ❑ Owned and Managed SMA NAME: Northwest Water Systems,Inc. SMA Number:119 154 Managed Only • Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) Agricultural EHospital/Clinic X Residential Commercial/Business ❑ Industrial ❑ School El Day Care Licensed Residential Facility El Temporary Farm Worker CI Food Service/Food Permit Lodging ❑ Other(church,fire station,etc.): 1.000 or more person event for 2 or more days per year ❑ Recreational/RV Park 3.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) Association ❑County 0 Investor E Special District City/Town 0 Federal Private 0 State 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION W 73 Z m cn LIST UTILITY'S NAME FOR SOURCE r z z Vf _ N AND WELL TAG ID NUMBER. z 0 co -mt c n -n p pp m i D. m U1 D 0 y -n 2 Xi S r D X1 O --I p cc Example: WELL#1 XYZ456 u WI D m m m r m D D < m-< 0 n m m z 3,3 D m G) Z rn m 3 p3 T, A . ry zO H z O iD IF SOURCE IS PURCHASED OR INTERTIE Z r r U1 O E.)- `2 r O D Ur5 LIzgic3 00 Z4 3r m C c INTERTIED, SYSTEM * r r 33 m -n D D r- -1 z O m m z > P T. z -+ m O r 1 3 N 3 LIST SELLER'S NAME ID r r r z rm- r m m xt m z D n m z 0 0 0 D m m m -'co O m = O Example: SEATTLE NUMBER r D D cn D D A O -< z -r r < D m z z z .$ x -i z cn z m -u m SO1 WELL A ABR135 X X Y X 165 80 SW SW 12 22N 02W SO2 Well#2 BIY725 X X Y X 181 150 S W 12 22N 02W n___. 4 WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 86040 N SUNSET BEACH MASON A Comm DOH USE ONLY!DOH USE ONLY! ACTIVE CALCULATED APPROVED SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS , 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 73 99 A. Full Time Single Family Residences(Occupied 180 days or more per year) 50 B. Part Time Single Family Residences(Occupied less than 180 days per year) 23 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 0 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 1 1 0 28. TOTAL SERVICE CONNECTIONS 74 99 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 189 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? 7 7 7 B. How many days per month are they present? 7 7 7 '31. TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many total visitors,attendees,travelers,campers,patients 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 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 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 1 1 1 1 1 1 1 1 1 1 1 1 34. NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY 3 YEARS (One Sample per source by time period) O6. Reason for Submitting WFI: 0 Update-Change 0 Update-No Change ❑Inactivate ❑Re-Activate ❑ Name Change ❑New System 0 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: •A..nn• n•• /f\_ nfInn. --.-.. .-. n.-....• 0