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HomeMy WebLinkAboutWAI2023-00114 - WAI Health Waiver - 11/17/2023 415 N.6"STREET,SHELTON WA 98584 MASON COUNTY SHELTON.360-427-9670,ext 400 COMMUNITY SERVICES BELFAIR 360-275-4467, ext.400 ELMA 360-482-5269,ext.400 \ ' BuilEmg.Plan ing.Enwonmeetal Health.Comnunny Health FAX:360-427-7798 A. .I' •n for Waiver or Appeal ) Amount Paid � a. x"�i' Receipt Number: , 1 a3- � is WAI r�C , Z- Co I )'--1 Instructions: 1. Complete Parts 1 and 2 No determination can be made until these parts are fully completed. 2 Fees may be billed for waivers and appeals, based on the Environmental Health Fee Schedule. 3. Submit completed application with attachments to Mason County Public Health for review. PART 1. Applicant & Parcel Information Name of Applicant Lynda & Jeffrey Jacobs Telephone (206) 501-5787 Mailing Address P.O. Box 3029 City Belfair, State WA zip 98528 Parcel No 1 2 2 0 7 7 5 9 0 0 2 2 Site Address 644 E Alderwood Rd, Belfair WA 98528 Subdivision Name and Lot LOT: B OF SP #2330 PTN TR 2 S 5/94-96 PART 2: Nature of Waiver/Appeal ❑ Onsite: Class A Waiver 0 Food Sanitation Requirements ❑ Onsite. Class B Waiver 0 Group B Water System Regulations pa G=� ❑ Onsite'. Class C Waiver ❑ Water Adequacy Requirements r; Xi Onsite. Location WAC246-272A-0210 ❑ Building Permit EH Review Policies I ❑ Onsite. Holding Tank, WAC246-272A- 0 Appeal Enforcement Timelines 024i : Contractor Certification0 Appeal: Departmental Determinations ❑ 0 sne �J) Requirements -i 6�j Description of Waiver/Appeal(include justification additional material may be attached.): • Reduced setback from Owner's private well to septic drainfield from 100 ft down to �'' --- 75 ft. minimum,actual distance is 85ft. Well is up-slope of septic system. The on-site septic system using a NuWater BNR-500 meets Treatment Level B without disinfection and pressure distribution. The system has a timer, elapse meter and event counter to ensure the drainfield is not being overused. Area well logs are attac d Local wells show multiple till/hardpan and/or clay layers. Applicant Signature. - Date' «-11-2S Ovvts'�c.. &et-s-r_ u.o,V*ar jc,r Bw�af Rae,o-f R;132018 This form may be scanned and available for public view on the Mason County Web site. Peee I oft PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicabl= i Appeal ir.Waiver i None required Class A Class B Class ' c-C -- 2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/Standard revision): Zv-tC, - Z72.A- 021(3 3. Nature of Appeal: \� re-vs r htit'C.) -ckMAC. lOcaEVIL - r \ V•P-C-1, teAr\h1--e-13. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board Environmental Health Manager 5. Mitigating Factors: • 2 t 4- cOI\--F l - TLC 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. Staff Signature: A Date: t't�Zt!Z 3 PART 4: Determination of the Hearing Official .,.,The hearing official has determined that approval of this request will not adversely affect public health and is hereby granted. This decision is based on the following findings and conditions: ❑ The hearing official has determined that approval of this request could potentially adversely effect public health and is hereby denied. This decision is based on the following findings and conditions: Health Official Signature: ItA4 Date: i>"1.-01 ito,is d 8.13'3u18 This form may be scanned and available for public view on the Mason County Web site. Pegs 2 or>_ WATER WELL REPOT lip DEPARTMENT or 1.0„cofhaat2bwE42325 IFEY ECOLOGY LIEDEncEocifty wcnm 133NO BI8Es95 Tipp aorta Sate a(YMmMgon Site Well Name(dmae that as I 7:t3 am,Sept;L{ (p IInameelikabm o OddaltsBumNOINa War uMCadScateNo. P+W .ttm ®Dommde. ❑bbmld Pefmaget t RtVE,ry Owaee Nerve LYNDA JACOBS ODa.i.S DTeipuw amtWai PDU= ,YPD r well 5¢ae<AWE=664 ALOERWOOD Comenctlem■lw wog 0Allmmw ❑Deivm ❑reed a pet Tod Oh.BEI-FAIR Covog MASON amps*. 013bw Pros MAE- 0Mdaaay rah:00NQit5NR1e3132 4e2o7- 75-'- 9mv',J Dewd.m Dizacterofede6 O,tow i DNOtlmmyeadee3333 t tan evaiam.ppw dtraAsa am O4e IIXo CavespNDoMis Wan aye,whet was the wham tar Odes Use Vam, Yam TO 9aebea Skeet PlCwdu 1L.W k ® 1 C 2m m ® C 1-31 6 1 Location tm epal2 E WWMarC EWA( O 1 ❑ —3- 3. C 1 a C 1 ❑ NW '�SmttmTaysship 2221 ® C i C to. - _a C 3 ❑ ❑ 1 C L®mdo(Dem 4112345} !tWa Ova END TypoofpaRnaaas �aDmda lEmonDN�-t20.12;e5) w.orpmmdooc_ Da ofpmeedma—cbl_a StillierSLOWIMIStructitin Or SeCenollioriOltrriNiediert g• i pamsmadlkm—t m__t pebrmowdatra¢ 1 RaomdaaMdhSy*WE dams;tee Kwafu4Ymedc®d Om lirt.ed _ San OYw liNo rmsetOea.na wen EqupamumEst'aelmem.mew bomb amsoa To AlvgtameKeim® ®LAmr b Dmt_t 1 Cat?»Dstldtiemlat®Zseeq. 3 1)p DNo SUNLESS Mani.Mani. Maetd... tl(6 To i II enr_in Matte IL hum—tm-- . :CLAY&GRAVELMOWN 0 SD v=. Dinar a .dents— D.Sao tafr. CLAY BLUE 50 300 5 SwitlaMmrpodu:CYs ®No Silieafpetammill iL QAY&GRAVELBROWN. . 30D 310.. g EBitilubsidbc—tm___t !!GRAVEL CEMENTED H2O BROWN 315 335 ^m B.O¢Ovh Mtn OEM lbvtmbpiD 20 t I E 1WllwdlomL BE NTONITE DM swam ms6avmtls+amx OYw ®No 1 TAe vow DE*ofav 1 1 E. MdeudmWgddaaB c "amps Nmo GOULDS Tim 13U8 : R �. 1'evpiotadapOr-Ry+e ft D�ed�w� ■ ECEIVE© ■ w4p104e:Le - deiewehwemmaaea t • 8y 1YfL Dae6ZRLVTNR@1»ikB( z 8 3334. gak�egRa4 1 tam nalstrese:a « -a _).s 44btpalam�aa DR&10.2! �a. 9!°iBaP_yamiA Gh pt.• "4 ke Rap nLe mt.) al a Wetftam a Vostim iktaw _ 0 ONo Ws e", e _by I a 3 de thlE ieW ME StmNwaamr* In. li I.- Itek-1Ftdt_t 0aadwa azm O visa—NpasbSdeabseVtrEt al Z pwmpAfat4e.^amwMmv®pisvew0e-.2aOr®ma a.maeu ill d .ga®alwe a Mac War Iand Tone Wow Laid Tort Wac4w -- - — — — — — w Dern/m*0m 8et�vm—or oW tawderadr-m. o AhmypawRta®awn ktn. m. Dv. C &e1mYnDim_sa g rgR ae etw —•£ Was ep'a aWaDwi ooiel CYea SNa Stroya4-1.21 Completed lye fri21 d. WELL CONSTRUCnOR CBRT1ncsTTON: i ,a.aml=War emmartwwmtaaV fa cc rodou of a.z*AD.am WEewapl®v Inthsli WastringloE well .j codarsmdotrda Matmahmen and the iaboratioo masted above me taw to mybes:krowtedse and bdiat O t D!1 1 0Titan ME-PdmNm iUtompany e LYLE PITfS D C COOLWATER ORRLWGJNC. — I- 8reuo Address 10921 NW HOLLY RD Y • - TdeIJ0.1T13 �,r�. arty,eno-,2io BRE MERTON WA 98312 W Thee 93or of ),. Cmasaots Somiwes31DRoan RrejnionNo.GOOLWD6NOM Its 324-21 ECY O50-1-20(Rev 1U137 lbw,news damwrtean alrmwel at.please roll tee Wmn.Pna rat m SEO-1074872 Ponca: it hang Icus Pan call Tltjar]pmsdngrme Relay Service PenoawU aveeektittabikyems call 377-3336341. WATER WELL REPORT " >ot('NI 0 —.— EGOLOGY 1 mine m I1 r�1m BR tOo ✓ w. 1.r On 1 gyi%ry W.hr M C_ :rote 9. _ ___ ▪ paJ Lac EWrt . 7ICLIME' VpnFiurl nrcp1IN;rerEARN qm McOure mE BaFer01 (tm t rerW Ihrw nm a.21.0I NI, 3._ deSLM'. e —n ae9 a51 — _Iuzn:1, r w ..Ina _.. r' 3 m V RARE. 0e ! 11 I 33..loi 3 sse in. 3r a lutla ll I. .'I'4 _.._.. 1) 00,lay( r Otwmm Om trpcihir IT 1 r. rn r r . r IRTIC .r VTNcruvni I TA I. e 1er1 Norr. unu.oi re]xLf. J Nowlal From wu _'r __ 7m wan 3 5 c SC o re 35 D Ortm ; �Io� ( . ..s? u � .' I1 i Ctld(bW c 9YapBl . 250-I c G (food+. C X 30 d = y b tl 53 60 230 1 g "C13}L rt]08 c ay 1092 5 i w. ewn CleY 2W 10. - I. ne lav,re_ 8'Gk W 1 n sr.°wD i i 355 p c _.. stiF I - O II Y uv out coo 26° e 9/. 089. 00 '2 4. pl ia: .v. A .: µJ 0 M rnfd! 2W II 1212E r ' 40 - • .t RECEIVED , j r. r vl B WELL CONSTRUCT(ONNNOLICENSINGOKMEN041 m,JW 04 1026 s..: ta - . 9 11 _... I _ .xc T e — Je. .0 V f Z ; I vLL -mu ..al n. .... .a: o.c ua,,I. . _.... ._ S' � . ___ .—___ - — I II W d, a - :— -1 w rIt Ay c ,prr 1 I-- —I Y1r1 p m.rm mr m6/12/2Y _. I no _WO; — —_ 11 t 1 I.(IA l lil Cl ION({RI I1I 110At J . 1 I :nil .(01. 0ce I u..II 8 .u.. rtr _ei V WJ 90 n4ry41400 000 cae. J p+ 10 _a. ) lI. It n e LI l Fmllyflapic _•r[Hu (TR r .Devi 1 Ing 1 iSc ..,. C L \ -5\ -3a_+^-. 1.0.10..340 ip S Fa+n R' 22E II-n,WA 951.'8 .r TRAIN TRAINE F \bn^.r..I wr,qa r.1 IOC. .. 'p :im:we 1. i ra A DAWS0 180: yp_July 2020 e :v rv. r{ yr r ♦.ea2 r : .... rA ..r. a+ FdeOriginal and Fat Copy with NCete d intent W 093247 Department alEcology WATER WELL REPORT O f^..Sea;N Copy-Oweees COPY UNIQUE WELL I.D.N AGE73S TNrd Copy-De fiers�y rig Ain STATE OF WASHINGTON Water Right Remit No. WA CC (1)OWNER: Name EREDBNDD)ANN pia Address PO BOX 865.BELFAIR_WA88528 =y (2)LOCATION OF WELL: Car MASON - SW 1/4 _NW 1/4 Sec 7 T. _22 N.R_ f W.N. • (2a)STREET ADDRESS OF WELL(or nearest address) 570 E.ALDERW00D IW y TAX PARCEL NO. t22DT3539961 • (3)PROPOSED USE: ©Dannee D blotted XMunicipal (10)WELL LOO or DECONMISSIONWG PROCEDURE DESCRIPTION: ❑Irrigation ❑Teal Well 0 Other rmmedan Otemee by color,candor,m at maaw and sauna and the kind and C ❑DeWatr named ee•mean in each*stun pwwlaad.an It law Ma awry for ewewny O aerrtaman. wawa all war naumwtl. (4)TYPE OF W0RK: _Centel number dwal(a mole than oral _ - -- -- C N4TERYLL _._ FROM�.....TO O GOewenell Doug 2'+ ❑Deaearad ❑Dug ❑9aed BROWN SAND AND CLAY 0 37 19 XRemmdioned XCaae ❑Doan GREY CLAY __. . 37 8 24 XOecommlasim Oz Rotary Li Jetted BROWN CLAY AND SILTS 235 24Q (5)DIMENSIONS: Diameter of well SIX inches BEANS OF SAND GRAVEL WIB 240 260 Dolled 2S0 fest Depth Ofcompteted well 260.- . it —.7 C (6)CONSTRUCTION DETAILS: _— _. i 4) Casing Installed: rice A welded 6 ' Diem.rrom +1 5_ ft a_25E ft '• ' Unite Metalled ' Dem.from _. . It to It i O ETMeade —.— ' Dam.from _ _ ft to ____ft. T7 P.damadone: ❑yes XNO C Tare a perforator used_ __. ___ • SGE of pub tiau in by in. CO PerfOratid.FM _ 1 M1ro R e3 pe.torationsfrOm - ft to ft —__ _. --_ __.. . .___ — L... ___ ❑ per/maims from i rtro ft al s Screens: �JYes Deo X%K-Pas Lmaeon 254 Tbanueaurees Name JGHNSON • Type CTAINI FSS STFFI Mane No. TEL C Dian. 6 sot see 14 born 255 ft to 260 it -- — _-- ... CO Dam. Slot site from ft to ft i.. 10 Gravelrlltar packed: Dyes LNo ❑ Size ofgrneleaad I _ — Material placed Fan ft to h I— Bathes wed: �vn Grvo rat wbaadapthx ..�8__._ft O Pm"laid in seal BENTONITE fricsrvyjEbin Z Did any strata moan unusable water? Dyes XNo y Type or water? Depth of seas _ _ DCEc I 0 )al( e) Method of sealing strata Of —...._— I 'O• (7)PUMP: Manufacturer's Name RFRNFdY --.._--_— ____ Wu41iw_+ett S(mate— `f Two: %IR ._ HP. 15._ - — ear ireIII O I hcolooy Of (8)WATER LEVELS: lerlOsudaa eleetion O aloe mean she ideal n. won sreneo W212002 .tea. compremd 8!7y7002 .tg V• Maim level __ it Palest top of ow Sn)7002 WELL CONSTRUCTION CERTIFICATION: DI Median pressure la per square inch Date_ _ cesmspmm d cte senor accept responses-pry forcon.n,con of this well.and its Artesian water rs consoled by_... ___ — cnpiance with art WasangLLm well construction sanders. M1ateriale urea —I :aTee;a-) and the informaon reported aWb are true ID my beat kno.Lhj.and relief. C (9)WELL TESTS:Dma.own is amount"inn let es leeno blow"Clew ID Wan a pump test made? i,7jYas XNo If yes,by whom?TDDC Types Print Nana 1tISiH0 .MS oeu7ninaT.n Llana9 No. 2147 E YYeI 15 gal mein.with 2,5 ft draw-dam after 4 HR hrs Yid: gallmin.with ft lowdown after _ ore. Trainee Name License Nd. Ili Yield gavm1n.wen _ ft bewam after __. era. Dnnmg Company TOP OOG DRILLING.CO Q. Remaly data(tone taken as zero when punpluned ofp(wale tree(nreesured 'TT t �� ❑ from well top a water woo (Signed) lF ^^''•'�_y. yoi (rends NO 2147 Time Waterw Letel Time Water Le Time Water Mesa (Donee onwr=nomd .0 5 143_._ AOGress PQ13922227_BELFAIR.WA. 98528 I— Cpntacnrs Regavanm NO TOPTKtQCOURA Date 8/1081002—,to see d ass BM2002 otau Bailer test 15 r1N.mem.aim 5 ftdnvd°^"anar I hrs. (USE ADDITI0WIL SHEETS IF NECESSARY) Meet —, gal/min. tor m .with e set at R tiro. Ecology is Equal Opportunity and Affirmative Adi l ters a employer. F Mnean lbw- Be•m. Date 8/6TJ007 spaced accommodation needs,contact to Water Resources Pmgrama Temperatures water Was a Mania analyses made? litre In No (380)4O7-6ECO. The TDD number N(3W)407-6003. 1 �tibli l +c� 50.22• - eaS �r 1lN56 9 • `f‘k _. vial_ ,titp Bs to DF $ S • N°tisE •c` F0-ra„k5 rz • ® of `'� 565Lopp /114 C• • Iti r' i ____________j . _ — APPROVED -�_' _ Nov 2 i 2023 uaSO4C.,d4II•.YTP, ",i',1.HEM' r1 `ari Cv'c& locale on ( ) 3"x5p' prtmar OF trer`cw-S 5' O.G. with 6o eqs 172.v- restr v{ ba,Wel ,C "m"11- AsPA,1, 7 '-' 'qldPr, , L(4/hda JaCohS ec1 ?afcef#*12207-75-900 22 0Audio-visual Alarm is • bk4 E Aiderwood Rd 3 Cleanout ' SCAIe: ( = 40 O 500 CraRon Pre-Trash tvnk t as1 l i L ' I Ye.. , J. OS N 1,000 Gallon Pump Chamber N� s,ewes :n\.}. W 0. i - Shey\ g, 1LA 20Y JOHNSOEN .:?1 0 Valve Control Boa kkitLE SIONR" \t, � �i _ N:p Ur'17.2