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Home My WebLink AboutWAT2025-00125 - WAT Application - 4/30/2025 (2) WAT 2025-00125 „0.. L,a 415 N.6th Street 0J `�: MASON COUNTY Shelton,WA 98584 Shelton:360-427-9670,Ext.400 •1 ' ' COMMUNITY SERVICES - l3elfair:360-275-4467,Ext.400 %f i,, ;•ti- Building,Planning,Environmental Health,Community Health F.Ima: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 this application. Part 1: Applicant/ Parcel Identification Name on Applicant: Dennis McGovern Date: 04/30/2025 Mailing Address: 424 N. C St. Tacoma, WA 98403 Phone: 253-797-6159 Parcel Number: 12019-13-00010 Type of Water System Reason for Application f / Public/Community Water System (2 or more V Building permit connections) ❑ Division of land: O Individual water source (one connection), #of Parcels? SPL O Well 0 Boundary line adjustment O Spring/surface water 0 Other(explain) O 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: il Public Water System Name of Water System: Smith Cove Water Facility Inventory (WFI) Number: 13651 T (write "none' for two-party) Ve I am the manager of this water system. The water system has been approved for 36 services. There are presently 17 connection(s) in use. This will be the 18 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 state and local regulation. Print Name of Water System Manager ��Melissa Coxx on behalf of NWSPhone 360-876-0958 Signature of Water System Manager!.//1. , 1,1ki �`Jfe?' on behalf of NWS Date 04/30/2025 This form maybe scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Re\i etl.1,27.2O I 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) V 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. 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's Signatures: Environ. Health:J U.Anderson 07r31r2025 Date 7/31/2025 This form may be scanned and available for public view at www.co.mason.wa.us. i'a<,e 2 o1 WATER FACILITIES INVENTORY (WFI) Quarter: 2 // Washington State Deparbrent of FORM Updated: 05/08/2025 ��Health Printed: 7/31/2025 ONE FORM PER SYSTEM WFI Printed For: On-Demand Dim ion of Cuv,rvnrnenbJ I lentil: Office of b,i,,kinx Water Submission Reason: Other 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 13651 T SMITH COVE MASON A Comm 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS KEVIN R. ODEGARD[OPERATIONS SUPERVISO] SMITH COVE ASSN MANAGER NORTHWEST WATER SYSTEMS INC BILL RYBERG PO BOX 123 90 E CASE VIEW WAY PORT ORCHARD,WA 98366 SHELTON,WA 98584 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS 7245 BETHEL-BURLEY RD SE ADDRESS CITY PORT ORCHARD STATE WA ZIP 98367 CITY STATE ZIP 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)876-0958 x113 Owner Daytime Phone: Primary Contact Mobile/Cell Phone: (253)377-1865 Owner Mobile/Cell Phone: (360)860-2050 Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone: Fax: (360)876-4196 E-mail Kxxxn@nwwatersystems.com Fax: E-mail: bxxxxxxxxg@aol.com 11.SATELLITE MANAGEMENT AGENCY-SMA(check only one) ❑ Not applicable(Skip to#12i ❑ Owned and Managed SMA NAME: Northwest Water Systems.Inc. SMA Number: 119 IsE Managed Only • Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) ❑Agricultural ❑ Hospital/Clinic Residential ❑ Commercial/Business ❑ Industrial ❑ School ❑ Day Care 0 Licensed Residential Facility ❑Temporary Farm Worker ❑ 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 13.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons) 1orAssociation ❑County ❑Investor n Special District ❑City/Town ❑Federal ❑Private 0 State 35.230 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION fn x m Z m 0LIST UTILITY'S NAME FOR SOURCE 1- 13z Cl, 1-f v cn Cl)1- m 0 AND WELL TAG ID NUMBER. 2 Z < cz T 7J m-t O Cl, cn x :a mi c Example: * m n 71 m cn 3 m O - O D m^< z A -+ D z ZO 0 z IF SOURCE IS PURCHASED OR INTERTIE r r 7111z -4 rliDDZ N mm c z cINTERTIED, SYSTEMmT T _ T mD D r z O m m z D .n0 zr C 3 z D a I Z - i _ EiO m z 5 mi G7 Example: rr r G r r m m m z D � o 0 0 0 v -mm m cn z x o m SO1 WELL#1 BAB701 8" X X Y X 236 49 NE NE 19 20N 01W DOH 331-011 (Rev. 06/03) DOH Copy Page: 1 WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 13651 T SMITH COVE 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?) 21 36 A. Full Time Single Family Residences(Occupied 180 days or more per year) 14 B. Part Time Single Family Residences(Occupied less than 180 days per year) 7 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. 0 0 0 28. TOTAL SERVICE CONNECTIONS 21 36 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 28 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? 5 5 5 5 5 6 6 6 6 5 5 5 B. How many days per month are they present? 8 8 8 8 8 8 8 8 8 8 8 8 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 or customers have access to the water system each month? B. How many days per month is water accessible to the public'? 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) 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: DOH 331-011 (Rev. 06/03) DOH Copy Page: 2