HomeMy WebLinkAboutWAT2026-00134 - WAT Application - 7/9/2026 Docusign Envelope ID:44A351 EE-1069-8AC2-8028-EC8908F18FCD WAT LULO-UU I,54
MASON COUNTY
w COMMUNITY SERVICES
•
Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 • Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. Nodetermination can be made until Part I 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: Jacob Ehlert Date: 6/9/2026
Mailing Address: 538 SE Dogwood Rd Phone: 360-551-3963
Parcel Number: 22325-50-06004
Type of Water System Reason for Application
l Public/Community Water System (2 or more ® Building permit BLD2026-00543
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ 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: Mission Creek Tracks
Water Facility Inventory (WFI) Number: 55320C
(write"none"for two-party)
O I am the manager of this water system. The water system has been approved for services.
There are presently connection(s) in use. This will be the connection.
I 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 property already has a connection and a meter.
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.
Signature of Water System Manager �E� . Date 6/9/2026
Csg
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018
Docusign Envelope ID:44A351 EE-1069-8AC2-802B-EC89u8F18FCD
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/planning 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)
y? 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.
0, 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:
7/9/2026
Environs Health: Date
CSD°Director: Date z oft
WATER FACILITIES INVENTORY (WFI) Quarter: 2
FORM Updated: 12/22/2025
Printed: 7/9/2026
ONE FORM PER SYSTEM WFI Printed For: On-Demand
Submission Reason: Contact Update
RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@doh.wa.gov
1 "SYSTEM ID NC) 2 SYS M NAME 3 COUNTY 4.;GROUP ,5:•T'Y'PE
55320`G MISSION CREEK TRACTS MASON A Comm
6,.PRIMAY CONTACT NAME&MAILING ADDRESS 7 OWNER NAME&`MAILING"ADDRESS
;
KEN D.LOOMIS MISSION CREEK TRACTS TREAS.
PO BOX 86 MICHAEL D. BERREMAN
BELFAIR,WA 98528 PO BOX 71
BELFAIR,WA 98528
STREET ADPRESSIF>3IFFERENT FROM ABOVE �,..,., STREET ADDRESS IF DIFFEt2ENT FRt`M ABOVE
ATTN ATTN
ADDRESS ADDRESS
CITY STATE ZIP CITY STATE ZIP
9 24 HOUR PRIMARY CONTACT INFORMATION 14:OWNER CONTACT INFORMATION
Primary Contact Daytime Phone: (360)731-6444 Owner Daytime Phone: (360)275-5508
Primary Contact Mobile/Cell Phone: (360)731-6444 Owner Mobile/Cell Phone: (360)731-1016
Primary Contact Evening Phone: (xxx)-xxx-xxxx Owner Evening Phone:
Fax: (360)275-0745 E-mail: kxxxxxxs@wavecable.com Fax: E-mail: mxxxxxx9@wavecable.com
II SATELLITE MANAGEMENT AGENCY.SMA(check only one)
Not applicable(Skip to#12)
0 Owned and Managed SMA NAME: SMA Number
0 Managed Only
Owned Only
12.WATER SYSTEM CHARACTERISTICS(matlall that apply); ._.
.. —
[]Agricultural 0 Hospital/Clinic XResidential
0 Commercial/Business 0 Industrial 0School
0 Day Care 0'Licensed Residential Facility 9Temporary Farm Worker
0'Food Service/Food Permit O Lodging DOther(church,fire station,etc.):
1,000 or more person event for 2 or more days per year fl Recreational/RV Park 0 RTCR Seasonal System
3.WATER SYSTEM"OWNERSHIP(mark only one) 4 STORAGE CAPACITY(gallons}
0 Association 0 County Investor O Special District
Q City/Town Q Federal 0 Private 0 State 48,000
19; 16 17 18 19 20 21 22 23 24 r�
SOURCE NAME INTERI IE SOURCE CATEGORY USE _ TREATMENT: DEPTH SOURCE LOCATION
m mA'.
LIST UTILITY'S NAME FOR SOURCE r Z y 1 ro sh
AND WEh1 TAG ID NUMBER. z O
tn" .
Exampie. WELL#(XYZ456', ' o m' ,T c o : m
tm" Z tit '{� _.. p �"' C' •� -_i -• _r �$'D`
IF SOURCE 1S PURCHASED OR INTERTIE r r ut G�"PO A G A w o O o '-! t-•
I[TERTIED SYSTEM;;" gg '+t d -n,,`�" ]y p. r , i , O m 'm .z 7p A z : s o r z r. C) z
LISTSLLER'SNAME A SID" 't" "
a s r .r r, ;
-+- Example: SFATTL E " IUMBEI r a v "47 v m
In
801 WELL#1 WW X X Y X 143 40 NE NW 25 23N 02W
S02, WELL#2 WW X X Y X 154 30 NE NW 25 23N 02W
S03- WF(S01&S02) X X Y X 143 70 NE SE 25 23N 02W