HomeMy WebLinkAboutSWG2007-00133 wel2007-00013 - VAR Application - 1/23/2007 r
RECEIVED
MASON COUNTY JAN 2 3 .-,7^.j
DEPARTMENT OF HEALTH SERVICES EALTH S€t�VTCFs Fs :
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VLOCAL(360)427-%70
FAX(360)427-7798
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Amnant Paid'
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Instructions
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Name of Applicant °' '
� � Date
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Subdivision Name and Lot
rAKi z: Nature of waiver/Appew
❑ On-Site Sewage Requirements ❑ Food Sanitation Requirements
_.._::
e r^•••• 2-0950- ❑ Group B Water System Requirements
o Location, WAC 246-271-09501 P
o Holding tank WAC 246-272-12501 Water Adequacy Requirements
a Certifaatton contractor(Pumper, ❑ Departmental Determinations
designer,installer. O&MSpec)requirements ❑ odw
(J(•.$ JPUU➢Ut W1➢VGU lltltlWl IWAUUGJWlU1 .6NVy YYW UVLLY uY4YW lLLG] W upyuW).
Applicant Signature: ��
H:IWUATAWRUarblWAIMA WY Upaue:lVb ba",trie
PARTS: Health Department Evaluation(Staff Use Only)
IA.Type of Determination Required: 1B.Type of Oa-Site Waiver(if applicable):
❑Appeal t<Waiver None required ❑Class A ❑Class B ❑Class C
2. Identificaton of Specific Code/StandaidMetetruination(include date of determination or latest
codetstandard revision):
.Water adequacy policy
3. Nature of Appeal:
-- Receive building permit prior to well being drilled.
4. Heating Official:
❑Board of Health ❑Health Officer
[].Pollution Control Hearing Board Health Services Director
❑ Certified Contractor Review Board 16-Bavirotmental Health Manager
5 Mitigating Factors: -
A) wFcw — 00o13
B) DOE# iIg
C) Two vicinity well ogs
D) Letter from well driller
-E) Condition permit:Well log and satis bacti to be submitted prior to occupancy.
6. I have reviewed this waiverhmiance requat. It is complet4 and midgad"regtdred by state and kcal
polity has been subm'Ced.
Sta!£ Date: .
PART 4: Determination of the Hearing Official
The hearing official has detumixd that approval of this request will not adversely affect public health and
\\\ is herebygt'trnted. This decisioa is based on tta following findings and conditions:
❑ - the hearing official her determined that approval of this request could potentially have an adversely affect .
public health and is hereby denied. This decision is based on tho following findings:
Bearing OfHciat Date: Z3
HAWAIVERWP.DOC Updates NovanW2J,19"
COOLWATER DRILLING,iNc
10921 HOLLY RD NW
BREMERTON, WA. 98312
360-830-9005-FAX 360-830-9216
COOLWD1962B6
1-19-07
COOLWATER DRILLING INC HAVE A CONTRACT TO DRILL A
WELL FOR E.K. & CAROLYN LYBBERT FOR PARCEL
4 22330-50-00286 & 22330-50-00286