HomeMy WebLinkAboutWAT2026-00088 - WAT Application - 5/18/2026 Fes,
WAT2026-00088
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MASON COUNTY
S Oo W4227.%70.t_.t 400
Public Health& Human Services tkiL,u U4.17$-r4A7.litt 4's)
Application for Determination of Water Adequacy
Instructions
•^ bi;;; r--k!Pant No de1e c t rtaadr mtd P K 1 is$'u y axnpo1ed
nip !4 only t pWtor,of Part 2 gtØymg to Tho typo of water cony edron uted
3 Sutx;e astpek►C a f c tr' any requi ed auadtnWrtts for revsew
s�^^'9�.,:t _ ►'tom_'t r°�'' f�t4 "'•rt rri5i..° „thf.; 2 "'°�'`3!7
Part 1: Applicaniu Parcel Identification
N� of Ag ,: 1t �saa i3>yv J tti _ Date y Z y
}day. g Address irss Cu ua,.,, v✓A Ptsorl! 3(0. sZ3, oZgo
Pa^cra N�'nbt.=r
Type of Water System Reason for Application
Rib : ty Wuiex System(2 or more f B :ng perm
t3 Dn+ssion of land
C I a J l wmer source(ono connection), K of Pa' ? SPt.
0 wet xt,rfact►lnrat r O Boundary l ad.rssraertt
S g' 0 Clew(expla n)
0 Rep1acemert or Remade)(case indicate name
tf you have mare than one res*Ience conneaed of water system Wow of itppabe--no
to t*.rs iwg.check the Pubtc1CommunRrty WWPor s ^.azure requ=fed)
,Sye7 box
EH APPROVED
Part 2: Water Connection Information
Rhonda Thompson 05/18/2026
ate the season appropriate for the typo of wet& c_i tJt toted t
Public Water System
1%8=of Water System _j d �-`�_ t o r r
Watts Fact ty inventory(WFI)Number r � ... (wry z-non r for two-party)
l am the m. ngtr of this water system.The wales sysrein has been approved(or services„There
are presently —cennecUon(s)in use. P-s w:1,be the Luinean
I am the manager of this system This cennecXioowad be to upgrade or tie the use of an axtst3ng
caonfie,a�ort on this system(Le-reaeuona1 to tub L'ne) Please me c to on the following the the nature of
tts change
This water system is able and wt t;ng to{ Se water to the(these)conned on(s)with Ou exceeding the
t is of the water system or any ltrr>ts set by state and local n[egsslai,on
Pica N e of Water System Manage,
� :u�a rsf Water Systa trlinager _ f ..� Date
this(wm may be scanned and available for public view at www.maiaIityy
J Jf t:.x tr+ :atr ttn:ss!¢c•}."se_/ t9's of_
Brian Hellenthal 1 '
WATER FACILITIES INVENTORY (WFI) Quarter: 3
FORM Updated: 05/14/2026
iPrinted: 5/18/2026
ONE FORM PER SYSTEM HEALTH WFI Printed For: On-Demand
^ Submission Reason: No Change
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
O5'731;4 . °:WEBB HILL MASON A TNC
.6 PRIMARY CONTACT NAME&MAILING ADDRESS 7 OWNER NAME&MAILING ADDRESS
KEVIN R.ODEGARD[OPERATIONS SUPVI GETHSEMANE MINISTRIES PRESIDENT
PO BOX 126 BRIAN OR KAREN HELLENTHAL
PORT ORCHARD,WA 98366 PO BOX 1144
SHELTON,WA 98584
STREET ADDRESS IF DIFFERENT ..mm
PROM ABOVE TREET ADDRESS IF DIFFERENT FROM ABOVE <:
ATTN ATTN
ADDRESS 1550 WOODRIDGE DRIVE SE ADDRESS 220 E.MISTY ACRES LANE
CITY PORT ORCHARD STATE WA ZIP 98366 CITY UNION STATE WA ZIP 98592
9 24 HOUR PRIMARY CONTACT INFORMATION 10 OWNER CONTACT INFORMATION;; =.
Primary Contact Daytime Phone: (360)876-0958 Owner Daytime Phone: (360)898-2752
Primary Contact Mobile/Cell Phone: (253)377-1865 Owner Mobile/Cell Phone: (206)851-5189
Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone:
Fax: (360)876-4196 E-mail: Kxxxn@nwwatersystems.com Fax: E-mail: Gxxxxxxxxxxxxxe@Gmaii.com
1 SATELLITE MANAGEMENT AGENCY x;;SMA(check only one)
0 Not applicable(Skip to#12)
0. Owned and Managed SMA NAME: Northwest Water Systems,Inc. SMA Number:119
Managed Only
Owned Only
12 WATER SYSTEM CHARACTERISTICS(male all that apply)O
Agricultural ° O Hospital/Clinic Residential
O Commercial/Business O Industrial E]School
O Day Care [] Licensed Residential Facility QTemporary Farm Worker
Food Service/Food Permit [] Lodging OOther(church,fire station,etc.):
fl 1,000 or more person event for 2 or more days per year Recreational/RV Park 0 RTCR Seasonal System
3 WATER SYSTEM OWNERSHIP(mark only one) 4.STORAGE"CAPACITY(gallon]
O Association O County _ ]Investor O Special District
0 City/Town 0 Federal Private 0 State 35,000
15 1B" 17 : 18 19 2Q 21 22 28 24 �.
S;OURCIr NAIYtE '"� „ INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
m n
LIST UTILITY S NAME FOR SOURCE z z cn 1
ANDWELLLTAGIDNUMBER z CI) O - n �� n .. C)
G Example: WELL#t XYZ456 >z IF ra z xr o T +' O
SOURCE IS PURCHASED OR INTERTIE : r rn G� GY O y �
F
INTERTIED, SYSTEM -n rn '° Z! m .LIST SELLER S.NAME, ID m m rn m m �+ O zrn off-{ =i 2 s - r o�, -�•_ m, s.
Examples,S ATTLE : ,y NUMBER r o o o o M .M�;-c z -T r a m z 2 z S . Z .. o ; z� T mA_
-301 WELL#1 AHB612 WEBB HILL X X Y X 635 20 SE NE 13 21N 04W
DOH 331-011 (12/2025) DOH Copy Page: 1