HomeMy WebLinkAboutWAT2025-00179 - WQS Sanitary Survey - 7/22/2025 WAT 22 O2S _-_ 00 i 9
COU �� 4o , 6th Street
a: ASONShelton,WA 98584 400
Shelton:360-427-9670,Ext.400
--�'` 7 Public Health & Human Services Belfair: 360-275-4467,Ext.400
Application for Determination of Water Adequacy
Instructions1 is
1. Complete Part 1. No determination can be madearwater c
onnecti le 11 tutilized.
2. Complete only the portion of Part 2 applying tothe type
of3. Submit completed application with any required attachments for review.
4. Ana roved buildin site plan must accompan this a plication.
Part 1: Applicant/ Parcel Identification
J- 44.tt'I�-t "�l t1 — Date: 7 . .�
Name of Applicant: �,�'� ��
C ��( <, 'LLf Phone: 21iJ0 ��1'1G(,3a~' i
Mailing Address: L�� �i; �L0
Parcel Number: . ___k \ 1 ' `�0_,',k
Type of Water System Reason for Application
J Building permit
Public/Community Water System (2 or more 0 Division of land:
connections)
O Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)________
S
O Other(explain) ❑ Replacement or Remodel (please indicate name f
of water system below if applicable-no �
If you have more than one residence connected signature required) `
to this well, check the Public/Community Water g v`) \'( (
System box. 06
Part 2: Water Connection Information U� L 1pL '1 �t7NL\' N ✓'
Complete the section appropriate for the type of water connection being evaluated: ., C�� dc&j��v '
Public Water System �ES`I ,ti
Name of Water System: �F l(''_;Lk) 1 0_. 4-,( ! S C,r) 1-1 rek Lt• .,,i-r C. L-%,( 13
Water Facility Inventory (WFI) Number: _ 36740
(write"none'for two-party)
n r'
,t ' I am the mana er of this water system.The water system has been approved for ,, : services. There
are presently
connections)in use. This will be the •�.,r"j donnection.
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. // �1 r�
Print Name of Water System Manager- 014 N 1�
1j. lVF's r Phone 36-0- 6 Q6-Z7 rJ
Signature of Water System Manager �-
,1,_ %.` Date Sul ' 1 025
This form may be scanned and available for public view at www.masoncountywa.gov
]:\EH Furms\Drinking\Vatcr
Revised 05/08/2024 i'aue I of 2
Group B Water Systems
f_ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth
ft.
O 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
l
these tests are noted on the water
well report.
R f thesults from these tests e water well report doles not ha pe a capacity test,
e acceted. If the water
well report cannot be located by applicant o
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.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health:
c /-11 tr/►'iS( Date 10/6/25
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
WATER FACILITIES INVENTORY (WFI) Quarter: 2Updated: 04/08/2024
FORM
/,' Washington of Printed: 10/6/2025
i Health ONE FORM PER SYSTEM WFI Printed For: 101 On-Demand
a;:•�+o„,#�,rtrtrrr.rnr.•rri.d;"" Submission Reason: Contact Update
Off oft.rirrkIwr Wohr
RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@da GROUP 5. TYPE
3. COUNTY
1. SYSTEM ID NO. 2. SYSTEM NAME A Comm
36740 D JESFIELD TRACTS COMMUNITY CLUB
MASON
6.PRIMARY CONTACT NAME&MAILING ADDRESS
7.OWNER NAME&MAILING ADDRESS
JESFIELD TRACTS COMMUNITY PRESIDENT
KEVIN R.ODEGARD[OPERATIONS SUPVI CLUB INC
PO BOX 123 JOHN NESTER
PORT ORCHARD,WA 98366 PO BOX 11
BELFAIR,WA 98528
STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE
ATTN
ATTN ADDRESS 91 NE KIMBERLY DR.
ADDRESS 7245 BETHEL-BURLEY RD SE STATE WA ZIP 98528
CITY
PORT ORCHARD STATE WA ZIP 98367 CITY BELFAIR
10.OWNER CONTACT INFORMATION
9.24 HOUR PRIMARY CONTACT INFORMATION Owner Daytime Phone: (360)275-4978
Primary Contact Daytime Phone: (360)876-0958 Owner Mobile/Cell Phone: (360)620-2345
Primary Contact Mobile/Cell Phone: (253)377-1865 Owner Evening Phone:
Primary Contact Evening Phone: (xxx)-xxx-xxxx 1 mail.com
Fax (360)876-4196 E-mail: Kxxxn@nwwatersystems.corn
Fax: (360)275-7451 E-mail: xxxxxxxxxxxxxxxxxxxxxxxxa@g
11.SATELLITE MANAGEMENT AGENCY-SMA(check only one)
❑ Not applicable(Skip to#12) SMA Number:119
❑ Owned and Managed SMA NAME: Northwest Water Syste ms.Inc.
X Managed Only
Owned Only
12.WATER SYSTEM CHARACTERISTICS(mark all that apply)❑ Hospital/Clinic fig(Residential
0 Agricultural � Industrial ❑School
❑Commercial/Business Temporary Farm Worker
0 Licensed Residential Facility ❑ p ry
❑ Day Care El ❑Other(church,fire station,etc.):
❑ Food Service/Food Permit —
❑ Recreational/RV Park
❑ 1,000 or more person event for 2 or more days per year 4. STORAGE CAPACITY(gallons)
3.WATER SYSTEM OWNERSHIP(mark only one)tl
Special DistrictCounty ❑Investor
igAssociat on ❑State 20,000
Federal Private
�City���Wr, 22 23 24
15 18 17 18 19 20 21 TREATMENT DEPTH SOURCE LOCATION
SOURCE NAME INTERTIE SOURCE CATEGORY USE
o
m (n z m v cp
Z 0 s D n
LIST UTILITY'S NAME FOR SOURCE O A n
AND WELL TAG ID NUMBER. Z Z c _ 0 O o _
cn > v A Z - m n r ^ c a <•n m - z
c• Example: WELL#1 XYZ456 m m A m n 0 7j m rn 3 xi -r+ xi -4 r y 3 D ur z O
n r r z 0 D m y 3 D A m z pp 0 0 0 -24 r n z Z
D IF SOURCE IS PURCHASED OR INTERTIE r r v) 0 O > `r r 0 D Co 0 -i D D D z Z r
z SYSTEM T T n m D D r 4 z O m m z i s _ = m CO m = z
3 SELLER'S
ID m m r A m rn -r -r m s m z z m z O O O e- m m m -i z O m O
cr LIST SELLER'S NAME Z A
NUMBER o o cZi o o A p -Zi rD < o m z z z 5 -4 z m to v m
Example: SFJjTTLE 341 68 NE SE 30 23N 01W
X X Y X
SO1 WELL#1 AHA918
Page: 1
DOH 331-011 (Rev.06/03) DOH Copy