HomeMy WebLinkAboutWEC2008-00052 - WEC Application - 5/8/2008 MASON COUNTY PUBLIC HEALTH
426 W CEDAR ST.,PO BOX 1666,SHELTON,WA 98584
SHELTON(360)427-9670,Ext: 352, ELMA(360)482-5269, BELFAIR(360)275-4467
WEB: http7//www.co.mason.wa.us FAX:(360)427-8442
Application for Waiver/Appeal
Amount Paid: ///L _ / ✓'
n Receipt Number: 10 —477 (Q ✓Instructions A/J o (�OLC r4 dV, 2-oDs '9�y��;-Z
1. Complete Parts I 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 Public Health for review.
PART 1. APPLICANT/PARCEL IDENTIFICAT,I/ON �y
Name of Applicant Telephone �J 3�7
Mailing Address of Applicant
City j?AJ' ?1 J(Z State "44 Zip 7 �j 2-
12-digit Tax Parcel No. Z Q Q
Site Address :Z (7 /Y�� P e r Ile-
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Class B Reduction in Vertical Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies P�, Group B Water System Regulations
❑ Location,WAC 246-272A-0210 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements ❑ Other
(Installer,Pumper,O&M Specialists)
Description of Waiver/Appeal(include justification,additional material may be attached.):
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Applicant Signature: // Lt_// _�.�`� Date: Ii
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Page 1 of 2 )Ol,/Cr Ldd Updated 8/10/07
PART 3: Public Health Evaluation (Staff Use Only)
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#ate of detejijunatlion or latest Code/Standard
revision) � �a,,zG/
3. Nature of Appeal: f _�
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Health Services Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigatin Factors:
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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: Date: 5 741��tf
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:
W M Q O rS
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: Date:
Page 2 of 2 Updated 8/10/07
Davis Drilling, Inc.
NE 340 Davis Farm Rd.
Belfair, WA 98528
275-5367
April 29,2008
To Whom It May Concern:
I have been contracted by Michael Olson to construct a private domestic well located at 20 NE Pond Ct.,
Belfair,WA 98528.Having Tax Parcel#22310-75-00080.Having drilled many wells in this area I do not
anticipate any problems finding an adequate potable water source. Enclosed please find a neighboring well
report.
Thank you,
Mike Davis