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Home My WebLink AboutWAI2023-00121 - WAI Health Waiver - 12/17/2023 - + IIP"litioili c MASON COUNTY =: i COMMUNITY SERVICES r. ylJr ^",��wY Building,Planning,Environmental Health,Community Health •t:rt\r:r` 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 W�e`/�Ap�eal Amount Paid: 1 U Receipt Number: Instructions + - 23,- 00\a 1 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 Identificationl Name of Applicant Q c'\0. — 9e \A Telephone(;11A173--.NV,VI Mailing Address of Applicant il /". .- `,`\- PNe 5\\I City �' �'C \� State W \ Zip \ \? 12-digit Tax Parcel No. , ` O X 6 -- b L) -- 0 `') 0 0 5 Site Address (.hc) , 'FrGr) C)' --V ` \Mc' : � ---) Subdivision Name and Lot V'Y,k`t1\:). \. `-A 3 \ c PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) Separation ❑ Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations ❑ Location, WAC 246-272A-0210 ❑ Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines O Mason County Onsite Standards 0 Departmental Determinations 0 Other Descr'ption of Waiver/Appeal (include justification, additional material may be attached. • I. s .. . �s_..` � IL 1a ' \. -.. Il► Ailk 15�' M �� i IIIMER iic l I,. .\`� [V•ERIMAR� tIRWM '�_ 1�• k\, 'cc-A\r, \• o �S•1 \ 4 , yP ct c\s o\ l"�t \� Applicant Signature:' M Date: 1 J \� C.)NC `J J:\EH Forms Waiver-Appeal Mason County Local Revised 1/20/2017 Pagel ot'2 PART 3: Public Health Evaluation (Staff Use Only) LOCO? 1. Type of Determination Required: Type of Onsite Waiver(if applicable) Appeal Waiver None required - Class A Class B Class C 2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/ Standard revision) 3. Nature of Appeal Separa ,n bei wee4 w�4c 296-272�-07 1o(1) ' Rake hvr� Zar'1+q 1 r ar] oS5 d i SaI on�✓1# %d an inliwtdv4l tvGi l Iron foOf74 to c /Ylt�1r' rim of Sevemfy-f ce fe_ f 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board 0 Environmental Health Manager 5. Mitigating Factors: — wul haS c! Cal F`i11 Iv r5 for 16-Soo- boloV,y(Ov11d 1&i&f. — !2 t?1 aF k*cs1a"I ve'l,c ( Sgo 4Cyo e�,,rd in 14c 2 (6- 7A-013o Tcbltvi - ka l (5 /lv1 vrl racUe44- f#G� drdtn ( l � 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: 42----- Date: l Z ( 7 V(oZ 3 PART 4: Determination of the Hearing Official ALThe 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: 0 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: Hearing Official Signature: 4/ Date: 1 Z f Ztrii 7 Zl J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 2 of 2 WATER WELL REPORT ; DEPARTMENT OF Notice of Intent No. WE51138 ti�`'•'= �-I ECOLOGYUnique Ecology Well ID Tag No. BNV806 Type of Work: State of Washington ❑l Construction Site Well Name(if more than one well): 0 Deconunission r r Original installationNOl No. Water Right Permit/Certificate No. Proposed Use: OO Domestic 0 Industrial ❑Municipal Property Owner Name Brian Reid 0 Dewaterieg 0 Irrigation 0 Test Well 0 Other Well Street Address 60 E Franjo Beach Dr Construction Type: Method: t7 New well 0 Alteration 0 Driven 0 Jetted O Cable Tool City Shelton County Mason O Deepening 0 Other 0 Dug fi)Air- 0 Mud-Rotary Tax Parcel No. 22016-50-03005 Dimensions: Diameter of boring 6 in,to 147 ft. Was a variance approved for this well? D Yes (]No Depth of completed well 147 ft. Construction Details: Wall If yes,ulmat was the variance for? Casing Liner Diameter Front To Thickness Steel PVC Welded Thread O 1 0 6 in. 0 147 .025 in. O I 0 O I 0 Location(see instructions on page 2): 3 WWM or 0 EWM D 1 0 in. _ in 0 I 0 0 I 0 SE r%-t/of the NW Vs;Section 16 Township 20N Range 2W O I D in. _ in. ❑ 1 ❑ D I o 1 ❑ in. _ in. O 1 O ❑ 1 ❑ Latitude(Example:47.12345) 47.221690 Longitude(Example:-120.12345) -122.942903 Perforations: 0 Ycs l J No Type of perforator used No.of perforations Size of perforations in by in Driller's Log/Construction or Decommission Procedure Perforated Rom ft.to ft.below ground surfsce Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: 11 Yes 0 No 61 K-Packer Depth 141 ft. infontution. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works Material From To Type Stainless Slotted Model No. Diameter 5" Slot size.016 in.from 142 ft.to 147 n. Brown silty sand and gravel,clay binder 0 5 Diameter_ Slot size in.from _ft.to a. Brown silty sand and gravel 5 13 Sand/Filter pack:0 Yes 0No Size of pack material-in. Gray silty sand and gravel 13 16 Materials placed from fL to_A. Gray silly clay,some gravel 16 20 Gray sticky clay,gravel 20 28 Surface Seal: 0 Yes 0 No To what depth? 19 n. Gray clay,hard,dense 28 69 Material used in seal Bentonite Chips Did any strata contain unusable water? 0 Ycs (E/No Gray silty clay 69 80 Type of water? Depth of strata Black silty sand and gravel,wet 80 123 Method of sealing strata off Gray fine silty sand,wet 123 135 Gray silty clay' 135 139 Pump: Manufacturer's Name Ty1e: Black gravel,fine to mediumblack sand, 139 II.P._ Pump intake depth:_A. Designed flow rate: gpw loose,water 147 Water Levels: Land•surface elevation above wean sea level 120 O. Gray fine sand,wet 147 Stick-up of top of well casing 1 ft.above ground surface Static water level 72 ft.below top of well casing Date 2117/23 Artesian pressure_lbs.per square inch Date Artesian water is controlled by (cap,valve.etc.) Well Tests: Was a pumping test performed? D No 0 Yes ) by whom? Yield _gpm with_ft.drawdown after hrs. Yield _gpm with_ft.drawdown after hes 'I Yield gpm with_ft.draw down after hrs. Recovery data(time__zero when pump is turned off-water level measured from well �� topto water level) D Time Water Level Time Water Level Time Water Level APR 2 8 2823 Date of pumping test WA State Dep 1Ctl1 [ i Hailer test gpm with ft.dravedow n after_bra. of E o C. 1F 5�f=JJ Air test 30 gpm with stem set at 140 A.for 1 has. Date 2/17123 yy �` f Anesiau flow gpns Temperature of water 49"F Was a chemical analysis made? ❑Yes D No Start Date 2/17/23 Completed Date 2/17/23 WELL CONSTRUCTION CEITIIFICATION: 1 constntcted and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above are tnte to my best knowledge and belief. J Driller 0 Trainee 0 PE—P• t N me Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2874 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponso License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 2/17/23 ECY 050.1-20(Rev 09/18) If you need this document in an altenrate format.please call the Water Resources Program at 360-407-6372. Persons with hearing loss can call 711 for Washington Relay Serrice. Persons with a speech disability can call 377-833.6341.