HomeMy WebLinkAboutWAT2026-00113 - WAT Application - 6/5/2026 WAT_20.26`-f1.O 1 1-3
°' MASON COUNTY
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Public Health&Human Services i,.i ,," , ,.
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Application for Detor'mination of Water Adoquacy
Instructions
rl -1 1nny'll'Pan I No delmminnton can be main unit Put I is hull rnngilnlnd I -I
Cuml.Jetn Only Ilia p011,0007 I:et 2 applying to the typo at warm 00000ctran till t,v,
Snlawt mnydclnd auden
ifsm with any mh rogmrod all nwnls In review."_n''J"'1—R'vt'^MrdJme air.elan 5101,1l aa:mrlLinn�ln�nj�p6rnfilm
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Part 1: Applicant/Parcel Id ntificatlon
l mug al Apl eti rt sl(•P�/ a!" Dale. I/`a /'?.r
?A, •.:AJdrnss D3_NG. Ptmnd
�.�.�-_-. J4v sialas
F`.a1 rl Numtrr a?al) JCL—_OJ.Q.aa
Type of Water System Reason for Application
fY I•,n:', t-nrnrmnnly Water System(2 m more VS.,kfmg pound
1,n•m•,Iun•.1
0 Dnlslan ul hod
pvl,:,du.d warier!.elatn limn uklnuctlun), 0 of Parcels? SPI
n Art•if ❑ boundary till:,ad)usunom -----
1 Sprmglsu'face water 0 O hinel h•..plunL—�-_— ther lospbin)-__—___ .
U Replaeumanl o:Hematcl lPlease and cue ow,
rr:,.r,have nu•A•than cum rrsidencv connector/ of valor syslnin below d applir iblu-nn
;n ins writ•dv:ch the Puhhaionrmumly Wider signature redalnnl)
'srro'm en,
Part 2: Water Connection Information
r.;inplcn the r vcl,on 0pllropnatn for the type of water connection being evaluated.
Public Water System
U;u;i1 ul Wohi,,Sy:narnai'1(j��,./:r/'r £
00 '✓1
W filer pacdity Invunlury(WFI)Nu ,mber h'Y! (wide none la.tyo-{m!WJ
Ian,flu manage of(Ills water systunl.Thu wafer nyslom has linnet aepruvud ion.5j srrvra. Ihan:
no pr0000liy —rannecban(s)In use This Will Iii,rho 'minerboil,
I , ni,1,n•,l.....gar of into syvin,n.l Ills 4b1u11,.V111 win 1w m )
l.u; n 1.1111 all ItII tool fCCfen".111111111,.
. 'to full brae).Please indicate oil Ina f011[rwinglirlr:line millun•Ii
Tins water system is alto and willing to provide water to Ihls(Ihpa)am0aehonls)valiant emucd.nc lit Ivmis If the v oler sytlem of any limJotby 51010 andlocal nigulaunn
N t Name of Water Syslnnh btanagur � ��G•W/1,?(j�/� Phone L)' 6.ys
,c,rp:nhon oI Water Syvlem Vanagor_ car
Group B Water Systems
Satisfactory baclonologicnl lost within last year(olfach to application).
Individual Water Well
It Water well report(attached loo IcalmnJ Duptl, It
❑ Well calamity Tool(mlarhnd to apptcah ghat
The wall rinllar alien performs wall capacity sts at the time the well Is Co.'lrueed Hus Its frmn
hone tells ale noted on the valor well report sults from these tests will be accepted.111110 water
wall repot cannot be located by the applicant or ill aler well report does not have.capauly Intl
11 well capacity lest,which provldus slabdizabon 01 draw and recovery dal,must be perlurn,tnl
by an licelused col tractor.
Ii Sahanrtory hartenolagical lost within last year(attach to applicabon).
Individual Spring/surface Water
Ii WDDE perint(attach pplicalion)
II Method of disinfection
I I I hdvn rn.Is."to behave Ihul tills water Ice can provide 9I least 000 gallons per day.unlpo,
protons warinr al a min of 2 pavans par Info based an Iho following observations
Author of Statement Dale
Rclnlwmmp lu Appbranl
Part 3: Mason County Community Services Evaluation(staff use only)
X Satisfactory Determinatlon: ---'
Tim duleln„mewl,uwa nut a0Jre•u a0mplacY of trio m,l,a, sr+lelh.guahinlo!•al adanunlc i..n 1111.A
water knleamldy u,lb lw heal•,or lluaranlo,uxnpll,vrn win as npphen No WUnE wnlnr rn„lu,r..ne,ryl„1,,,•,,
Rlwsrlesundad OOWov01 IrN,ulas rctuvomnnls of Snnnnry Gdo Tidu It Chnpb,r COO 010 Onuamu am.n,r
An•poaee for e1Wd,lg Pa,maa mho•alined AddlW,nnl Grn+nll M.ot000 lmll ronuboma,N may updv t,r,,,l l,'
to TOA HLW
Unsatisfactory Dolorminallon.
Nv,�.,nrs warol wrmuy d�lroh appoer 0000000 m rnceh au,m•Ms or n.mmnere„ran roe Or rau,n,me
PI
f-' yi,s.' toviower's Signatures:
[rerun Hrnitn "' r�`+
Dale LLC1
This form may be scanned and evsllabls for public view
innso---�countvwn goy
= CTER
MANAGEMENT
LABORATORIES tic.
{�f 1010 ioth Bt E.Tacoma,WA 20404
Dale Sample Collected Tune Semple County
+ Collected t
Type of Water System(check only one box)
.)iGmup A- ❑Gmup B ❑0ther
Gmup A and Group B Systems—Pmuide from Water Fpci itles Inventory(W9):
ID8 i 7 � rl ttJ
-Sy�Or Nam 't i•L,' i:C•trr .CV-t . -
Conlad Petson:•f V l l V i cJte d
Aay:Ptrorte( �.Q) t--9_,rJ Cell Phone:( )
Enroll Eve.Phone:( )
•tiedd oeidteto;(Plot NU name.add est and by ude)
Northwe.t Water Zysterds
PU:•Box 123
..pd t Gi:rskrtitc3.: Wi. . ...
9F' 66
Sainplo collected by(name): ^L r'cK ...-)
Spa clocationvfieiesamplecollected:' '1'Specialinstrudbnsorcommentz
1 ,Rouun,Dletilbulon Sample(NP) 2.❑RepastSample.(NP)
.Chtodnted:Yes'l.ND_ (aomatulpuaoneystemafterutsWLmunna)_.
ChbdntResldual:Total.Pree21 Unsabsfecrorytoudne lab ntmber.
3,Ground Wdter Rule Source SampleI . Unaedsta
g dory mains tolled date:
Chlodnaled:Yes__ No_
❑Triggered(AIP) Chlorine Reeldual:Tolel^Free_
❑Assessmenl,(AIP)
.4.Surface or GWI Raw Source Water Sample(Enumeration)
❑E.call ❑Fecal Fneed Yo_Na_
5:O Semple Ceneded for Informedon Onry:
v p" t(IVl�?ERRF,$IJITS;taTl:'
lfluaW7aemtyTAlalColtttotmPrasentand. , Salt
s `�-looGPenl ❑EcoRabsent
8élstlalpenIHyRaaulte.Total Colifdmr 11Ugrrd Scar, /tUQmj c
Fec6lCdgfom __I1tbmL. IIPG.;. n ml
R.pliumedt Sample Required: ❑TNTC ' 0 Sample too'old sYfA
(]4m(rWeVolume C3 DaInOged Con nor. ❑ t"
le uee lab Ralimi"Humbar
;fit 4_?5aIt
'Pec6fj9 Tenry C: MeundCede: '.1'r.0 �f•- -
i, IerpOr j+>� lab Ilse ONY,A J)?riyT411 ��.
ooe F,.,mi t9.a.n.Nilr).tl ,,,.a no,evv,re :w O b,,t ,NOr3%0l1,,)W! a In
rm ..an..w.+rotm
WATER FACILITIES INVENTORY (WFI) Quarter: 2
FORM Updated: 04/04/2025
Printed: 6/5/2026
ONE FORM PER SYSTEM
HEA LT WFI Printed For: On-Demand
Submission Reason: Contact Update
RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfii@doh.wa.gov
1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE
67800 N PLEASANT COVE - - MASON A Comm
6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS
KEVIN R.ODEGARD[OPERATIONS SUPV] PLEASANT COVE WATER ASSN PRESIDENT
PO BOX 126 TERRY L.WRIGHT
PORT ORCHARD,WA 98366 5221 NE NORTH SHORE RD
BELFAIR,WA 98528
STREET ADDRESS IF DIFFERENT FROM ABOVE- STREET ADDRESS IF DIFFERENT FROM ABOVE
ADDRESS 1550 WOODRIDGE DRIVE SE ADDRESS
CITY PORT ORCHARD STATE WA ZIP 98366 CITY STATE ZIP
9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION
Primary Contact Daytime Phone: (360)876-0958 Owner Daytime Phone: (425)785-6853
Primary Contact Mobile/Cell Phone: (253)377-1865 Owner Mobile/Cell Phone:
Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone:
Fax: (360)876-4196 E-mail: Kxxxn@nwwatersystems.com Fax: E-mail: txxxxxxxx7@hotmail.com
1.SATELLITE MANAGEMENT AGENCY-SMA(check only one)
❑ Not applicable(Skip to#12)
❑ Owned and Managed SMA NAME: Northwest Water Systems,Inc. SMA Number:119 —
Managed Only
Owned Only
12.WATER SYSTEM CHARACTERISTICS(mark all that apply)
❑Agricultural — -- ❑ Hospital/Clinic — i-- XResidential ^ —
❑Commercial/Business ❑ Industrial ❑School
❑Day Care ❑ 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 p Recreational/RV Park ❑RTCR Seasonal System
3.WATER SYSTEM OWNERSHIP,(mark only one) 4. STORAGE CAPACITY(gallons)
Association ❑County ❑Investor ❑Special District
❑City/Town ❑Federal ❑Private ❑State 11,000
15 16 17 18 19 20 21 22 23 24
SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
m z o
Ill z m c)
LIST UTILITY'S NAME FOR SOURCE y
AND WELL TAG ID NUMBER. F G) m 0 x D m
ca Z z — O m m
°c Example: WELL#1 XYZ456 D v N D m m m r m c g OT n j p
IF SOURCE IS PURCHASED OR INTERTIE r rm
z r r uINTERTIED, i
LIST SELLER S NAME SYSTEM D m m m m m -ai -11 m = m z z O =� i i ? 2 m y c 0 5 m v'
a r .r r z r r m m m z D n m z O 5 O c m m m -1 5 m = 0
m Example: SEATTLE NUMBER r o o G) o o z z -1 r o m z z z 5 X -i z m rn z 21 o m
S01 Well#1 AHB670 WW X X Y X 87 12 NW SE 03 22N 02W
S02 Well#2 AHB671 WW X X Y X 104 30 SE SE 03 22N 02W
S03 WF(SO1&S02) X X N X 87 42 NW SE 03 22N 02W
DOH 331-011 (12/2025) DOH Copy Page: 1