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Home My WebLink AboutWAT2023-00321 - WAT Application - 11/13/2023 wnToto - o 03 R MASON COUNTY COMMUNITY SERVICES a Ming,PlannM%EnNrmmemalHmitN�m nlry HeelN 415 N61'Street,Bldg 8,Shelton WA 98584, QG('C It /CD Shelton:(360)427-9670 ext 400 + Belfair:(360)275-4467 ext 400 O Elma:(360�q�'1da VoE FAX(360)427-7787 Application for Determination of Water Adequad0p 13 2023 Instructions 615 W. Alder Street 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. AL Part 1: Applicant/ Parcel Identification HEALTH Name on Applicant 1 1 m t�I V rn�'L�/ Date: 13,E &2� Mailing Address: 3 1 k� frll)ro2 1W rarM S IC41 hone: 360-aa9-& ,2 9 Parcel Number: Type of Water System Reason for Application 19k Public/Community Water System (2 or more Building permit 43GORD9 a - a1370 connections) Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ 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. / 0 �v _ Part 2: Water Connection Information Vp QpO 1 Complete the section appropriate for the type of water connection being evaluated: /� Public Water System Name of Water System: l XC_�J2 Water Facility Inventory(WFI)Number: nhh-e. (write"none"for two-party) I am the manager of this water system.The water system has been approved for o2 services. There are presently�_connection(s)in use.This will be the 2nd connection. ❑ 1 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. ]9EH Fotma\prinking Water R,,,e d 1.151018 Individual Water Well /Water well report(attached to application). Depth 0 Q Well rapacity Test(attached to application) 3 V cpm 7 /J apd. 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 htto://Qis.co.mason.wa.us/planning 15=]11,(/�22[] Water use or limitation recorded................................... N/A yes IY 1 ^� Well Drilled ..................................................._........ Date Z / 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) cµ+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: Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s). ^Reevi ees Signatures: `� ,• Environ. Health: ^C ' 1 �Y Y\/' Date CSD Director: Date 2 U2 Correction on address & parcel M WATER WELL REPORT CURRENT Notice of Intent No. WE06168 o.N:ml•1�e.pr-u.b,Y mmy-rm[,�"roly-a.Iu.. I,VOL 01'1 Unique Ecology Well ID Tag No. ALN353 Construction/Decommission C r"in circle) CD Construction Water Right Permit No.EXEMPT WELL Decommission ORIGINAL INSTALLATIONNolim Property Owner Name TIM MURPHY 'v3°1 ,oflnlen/Number Well Street Address 21 Mjrt)h}1 Farm Road naoM "Ua . vl A k ❑ IvamrW 13 M-.W'l City SHELTON County MASON ❑awum ❑ImWia ❑Tmwal Oaw Location NW 1/41M NE 1/4 Sec 20 TWI121N 0.3W soM ❑ a.a TYPEoFwoRG Mnv'[numbofmmifnmelM mml. — WWM Qi m' mpomp.aa ORumdili.ma .«aml:p D,a ❑m.e ❑airm O c.N[ 0Rumr ❑I."^ SIiILa�REQUIRED) �t Dog_ La1 MiNSec DINWRONs: amm.rof.al 6 iunn,aaam 1z0 e. Long Deg_Long Min/Sec DETAILS W111B A 32123.-11-90051 cansrRlKnon osrAlls Tex Parcel No. f:aNL mW'h 6 OIYn.Bmn1_Rm 11B A. INuaM: eLim NUYlm IAvn.6vm_n.lv__a CONSTRUCTION OR DECOMMISSION PROCEDURE Tlomdnl Di—aml n'm a' Fm.mim' p.s[rR[%mlw,dwuam,ua ofmu[nW UW vrv[rvrt,mtl W<kintl mtl Rrmrvde Ym N. ovum oflM maimYin m[M1me,un,pemmm,wilhulmn onem,y fa m[M1 tl,waeM Typ..fpvfaysuva Nr ti USE ADDITIONAL SHEETS IF NECESSARY.1 S12E.fp.ra__in.q�N.Wmafpva�flpa�fl.I._fl. MATERIAL FROM To Se.mu: ❑Ym ow. OK.ra Lawn BROWN SANDY LOAM 0 2 MmukmmY Nme BROWN GRAVELLY SAND,LOOSE,DRY 2 Is Tya Mwe Nv. BROWN GRAVELLY SAID,SILTY.MOIST is 38 0.un.�6M au avn ft- a. pime__SM dm am fl.m A BROWN SILTY SANDY GRAVEL.SILT 36 c..r.uRoa valve: Ye Np SpemammLmd TIGHT,MOIST 60 M.mdaepemesem Rm A BROWN PEA-GRAVELLY SILTY SAND, Bo 3u.k[esw:�Ym QN. TOH.601020 a LOOSE.WET 101 MNviammNeml °�.^r.en.e�Hlpc BROWN MEDIUM TO COARSE SANDY 101 pia e.rna.m;aN am.Mewm! ❑Ym ON. GRAVEL,LOOSE,WATER 120 Tnc.rwvel! Dq&mY,m M.mmMvlin6mne olf T,x:Mmuhw,al Nua Type: N.P. WATERUVIL&, Wdsuramaemi.n eb.w,emnvNrtl A S.N 60 abaow lW.fwal nee W311i A.wom P.mv Ih.pavnminN p,m—� Anm.on®YaxM1dlm% reNAvc. WLLLTFSIS: Dmwd.wnieumm�lwxalertl Nlwoe4 Nbw vale Nrtl WN.Pmq¢v mmei❑Ym mNo IfY4%xhan+ Yide veAanvdm na,.ubwn.M_�Ne. Yiai Wdan.waha6.wa.wn.flvNL Yiad: mlJmin.win__fl.dm+tlwn eRr��M. nemnymlolniue uhnm:w W,mpnpon,xa�1 Naxrh,W,nuuNlrw uWl m/v raahMl i/ .1 ..1 . -- - 'Tan wYal<:m 1Nm wYYIArm Does. — am.rlm__BVANo.wiA fl.amrdw..flv_Nv +Y U: '[p A..2D_yU,No.waM1.mnetlY 100 nfvL_In L2iL119 L'll L,Pj ,Ip I' '•;:I r!!V Amm.e Aox vP.m,Dam .• lr,— . nfwm 51, wm.amNml m.lyaelMei ❑Ym mN. SW DMA 'd-�4-O7 canlan.d D.M �-29-07 WELL CONSTRUCTION CERTIFICATION: I c rrutluaed and/or accept Tesponsiblliy for co mlmetimm of this well,and its compliance with all Washington well mnsWation standards. Materials used and the information reported above are we W my beat knowledge and belief. 0 Dian 010l.m O Traime yMm R,imI BRANDON HICKS n.ilhnO cm y ARCADIA DRILLING INC. IhillelruRinmrtmNa MMneme FG �� AJmw PO BOX 1700 -A� pfikrw mica l.[ma N.. 2163 �`ai Cip•.sole.Ziv SHELTOLTON WA BBSBa If Ir"INEK, Conm wr's Dasen lXenW na Reymxlim No. AROADOIOBBKt w,. 3I30/O7. pAlkh a¢.emrt' ECY00.1d00n+Nft DWI, Fqu.l ow--ryEmploys. Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer: Tim Murphy Well Tag#: ALN333 Site Address: 21 E Murphy Farms Rd, Shelton Depth: 118, Date of Test: 4/1 012 0 0 7 Static: 55.65' Pump Set: 100, TIME GPM LEVEL RECOVERY 1 Min 8.2 57.4 TIME I LEVEL 2 Min 21 57.5 1 Min 1 67.06 3 Min 21 57.6 2 Min 55.65 4 Min 21 57.6 5 Min 21 57.6 6 Min 28 60.4 7 Min 28 60.7 8 Min 28 60.75 9 Min 28 60.8 10 Min 28 60.85 15 Min 28 60.95 20 Min 28 63.9 25 Min 28 64 30 Min 28 64.05 35 Min 28 64.1 40 Min 28 64.15 45 Min 28 64.2 50 Min 28 64.25 55 Min 28 64.3 1 Hr 28 64.3 1 Hr 10 Min 28 64.3 Thurston County Environmental Health LV20a'r(D1370 412 Lilly Rd NE Olympia, WA 98506 380-887-2831 '11aUq.41ON COl]MY COLIFORM BACTERIA ANALYSIS Date Sample DdbcteC Tvne Sample County RONMENTAL `°"�' HEALTH 1 6 i z3 oaa N . 00 Y. Type of Water System(cmckanly olw boat )wPliveteaousehoid ❑Group A ❑Group B Omar Group A and(imup B Systems-Provide from Water FaoTAies lmambry(WFl): RECEIVED ID# Syrian Nana: OV 13 2023 ContedPwon: Day Phone: ) Z, Ce0 Phone:I 1 -/. Alder Street E-mail: Ee.Pholro:( I Smd msulta a(Pdntmi nam,addew wd epaee wandl aches) {f�ir/a7�lajj SAMPLE INFORMATION Sample mlleoled by(reme): Specific location or address where sample collected: Spacial inswNona or oanerwnte: 13 e .7rsrcu Type of Sample(mustdieck ony ma box of#1 Ihloeh N listed below) 1.❑Routine Disidbudon Sample 2.Repeal Sample(after unset routine) Chlcmnamcl.Yes_No ❑DisMbufion Sydem Churn,Reddual:Total_Fme_ Chlorinated:Yea_No ' d.Rewwaler Soume Sample Chlorine Residual:ToMI_Free_ ❑E.one-GWR(NP) ❑Pori-swr�,avn.gr uey..,meo,q Unwfisfacbry routine lab number. Felled Ys_No_ ❑AssoasmantMon"(NP) Unsat racbry roufi.mIWdate: ❑Otlwr 5 Sample Collected for tebrmetlon DNy ImrmdgA._ CmsWc 1Repmm on.— LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unutlefecbry Total Cofdam Prmldand Satkhc[ory ❑E.ro#premnt ❑E.m#absent No rmdeacled Replacement Sample Required: ❑Sample bo okl(e30 hours) ❑TNTC ❑ BacWal Density Reaufis:Totd Colifwm It00ml. E.w# 11001N. F=l Colibml 1100ml EmAxcf 1100mlL M*mc1Coda: SM922SB ❑SM9222D OaewdThne tJ, ❑SM9215R II'a 2-3 0 DU ambabefadeNateme, Doe Re Snpwxueea(bOxnaleeNkadtlW Labussoo - o a a 0 ( (n'?�+"N ' ' ,/1RONMENTAL 2206294 MASON CO WA HEALTH TIIIOTIIHIIYO ORPHT40pNI194007 Reo1 Fee $3'04 5'0 'PPages 2 Return To � u�� iiiiiiiiuiiu u� uiy V ED iimb}�u iA6ren YY441 lI••CC 91 E t6A4 FsrW6 RA JAN -8 Y024 S'1^ 4aal WA g85T 8I 615 W. Alder Street Grantor(s): (1) I lrrno}�y M�rPhT_ (2)_S�`1011-0n rn Cir ham/ Grantee(s): (1) PUBLIC —T— Legal Description (1) Lo+ R of SF �f-300 3 (Abbreviated loan:i.e. lot, block,plat orsection, township,range) Assessor's Tax Parcel: (1) 3 a 1 _Qk 3 - I I - 9 D O S a 51-3 - TLk -R3 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA) I (We), the undersigned grantor(s), hereby place this notice on record that the described real estate situated in Mason County, State of Washington is subject to water use restrictions and conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These restrictions and conditions are based on location of property and/or Water Resource Inventory Area or WRIA. WRIA: I y Maximum Annual Average Galleons Per Day: q 5 D gallons Dated on this�day of Jam, 20�. Signature of G to s / (1) (2) 1�Luc I State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, a Notary Public in and for the above named County and State,do hereby certify that on this, dayof January 20d , "�fm off'( personally appeared before me,who is known to be signer o the above instrument, a d acknowledged that he(she) (they)signed it GIVEN under my hand and official seal the day and year last above written. Lary Public in and for the State of Washington, ...... .� residing at cSk/ cP ° aA / NOT a"a = My commission expires:J06 OLZ_ 'err WASH'NG,`�..