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Home My WebLink AboutBLD2014-00797 Application for Waiver/Appeal - WEC Application - 10/13/2014 6 c-p'-'Id N 6o t$ooN COUv4 Public Health Always woddng for TsaWerhealthier Mason County PO Box 1666,415 N 6`h Street,Bldg 8,Shelton WA 98584, Jlj�l� OCT 1 4 209 LIIIIJIIII Shelton:(360)427-9670 ext 400 ❖ Belfair:(360)275-4467 ext 400 ❖ Elma:(360)482-5269 ext 400 FAX (360)427-7787 BY:_ , — Application for Waiver/Appeal Amount Paid: 1�S Receipt Number: Instructions 1. Complete Parts 1 and 2.No determination can be made until these parts are llv comoleted. 2. Fees may be billed for waivers and appeals,based on the Envitronmental;Heakh Fee Schedule. 3. Submit completed application with attachments to Mason County Public Health for review. PART 1. Applicant/Parcel Identification Name of Applicant Telephone Mailing Address of Applicant State 1 J R Zip 99001 City B.lj ,dW 12-digit Tax Parcel No. 3 2 2- 2 _ �� Site Address /6 t/5/ J � Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Class B Reduction in Vertical Separation ❑ Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations ❑ Location,WAC 246-272A-0210 A Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Onsite Standards ❑ Departmental Determinations ❑ Contractor Certification Requirements ❑ Other (Installer,Pumper,O&M Specialists) Description of Waiver/Appeal(include justification,additional material may be attached.): fr Applicant Signature: A Date: Revised 7-2013 This form may be scanned and available for public view on the Mason County Web site. Page I oft r PART 3: Public Health Evaluation(Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑ Appeal .4 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) J l 11 a 3. Nature of Appeal: ,414 <j of 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board ❑ Environmental Health Manager 5. Mitigating Factors: 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: �G,.1/ Date: (d l22 PART 4: Determination of the Hearing Official JX 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: Hearing Official Signature: �'K�•�t I ! / Date: /O 2 AY Re ,sed 7-2013 This form may be scanned and available for public view on the Mason County Web site. Page 2 of Davis Drilling, Inc. 340 NE Davis Farm Rd. Belfair, WA 98528 275-5367 To whom it may concern: I have been contracted by Sandy's Waterfront,LLC to construct a well for Rick Deardeuff.The well will be located at 16542 NE Northshore Rd.,Tahuya,WA 98588 with tax parcel#32220-50-02008 and the well will serve 16451 NE Northshore Rd.,Tahuya,WA 98588.Having drilled many wells in this area I do not expect any problems in finding a satisfactory water source.Please find the 2 enclosed neighboring well reports. Thank you, Mike Davis iP Pilo Original and FIrSt COPY with WATER WELL REPORT AppLicatlen No. Department of Ecology Second COPY-OWRWS COPY 57jilTz oir WASMG"N Third COPY—arillerx COPY verput Na. .. raw... J-J.....5h ore lid., T!!huY.a.... (1) OWNER. Name Zd....Le.a."yz.r ...................... .................... Add --. — ... I . ...........�A sea.....-.:-.. .. T22...s.. it...341M (2) LOCATION OF WELL: county...-L'.-sisan................................................ - Bearing and dild"ce from session IT subdivision owner Great_aind suo.. dive. 3 lot 1 (3) PROPOSED USE. Domestic la Industrial E3 municipal 0 (10) WELL LOG: Other 0 rotanguan:Describe b Color,Character Sing at maCanaL and Structure.a-, Irrigation E3 Tat Well 0 must thickness of war, and the kl;daud re at the met in me, atrarma prostrated.sorb at Islas one eaft"y each Chan" of larmalgam (4) TYPE OF WORM Owneor's number of wen......... XATmmmu�%" PROM TO (if more than am).... ...................... New WOU 1A Method: ON Cl nervel 13 Cable M Driven 0 tT Deepened 13 t)rowri Reconditioned C3 Rotary 0 Jetted ❑ (5) DIMENSIONS: Diameter of wou ..... ............ lachm solid -ravel 6, '. ter Drilled... ..4 .._tg. Depth of completed we '317 brown olety (6) CONSTRUCTION DVTAILS: Casing installed.......6�....... Diam. from ........0--- ft. to ft. cemented send & -ravel Throoded 0 ................ Dim.from .............. ft. to ................ T'. with uater Welded M ................ Dim. from .. . ...... ft' to ................ ft. 4 Perforations: Ywo Namsent & -ravel Type of pedocill" used....._.. ........... ............. ............................... SIZE of perforsuoull ............................. in. by . ............... In. L I.................. padmadow from ......... ............ ft. to ........ .............. ft. .............I........ Perforations frarn.................... ft. to ..................... ft.. n. ........... Perforations from ........................ ft.to ....................... Screens: YuE] vola Manufteturer's Nam............................*......*-""*.......................... Type.............L........................**.......................... Model NO.._...----._............. .............. ft.to ........... ft. t)im. .............. slat Sirefrom Dim. ............... slot sin .. .........- from .............. ft. to ..........— fl. Gravel packed: Yes 0 No 51 sin of Pavel; ............................ Gravel Plated from .......... ......................".to..................................ft. Surface seal'. Yes M NO,[] To at depth? .........19......... EL Cl r.-_- material wed In meal It-a.......... .....If-0'.i'X Did any air,&, contain maxambIll w&Wl 13 4'-.. Type at water?..._..._............... .. Depth of mtrmta............................ ------ L,M,d If sealing strata 08. . .................. ................................ (7) PUMP: Mmufactnrq'slesint..............lablmal......................I........._.. Tn.: ............gmmm.................................................. H.P.......a............ - LEVELS: Lnd-surfmca elevation (8) WATER above mean a" level.... ..... ..................ft. p— InA Static level -]12................. belowft- b"'O top of well Mtn 43- M.A—a Artesian pressure .............. ........_Jbs.per sa"I'd kWh Data................................ Artesian water 11 controlled by................. ' ')......... Drowdown Is @=Out water level Is (9) WELL TESTS- lowered below static level Work started............................. IV.......... COMP1.1 ...... ................ Was a Pump test mad*? Yes 0 NO JP I ...... . ge,"min. with f Yet.by whwa7 t;r Yield: ft. drawdown of hrs. WELL DRILLERS STATEMENT This well was drilled under my jurisdiction and this report i true to the best of my knowledge and belief. S,,,wry data (time taken as amo when pump turned 011) (water level measured from Well top to water level) Time Water Level NAME. .......4-ve-roo-n- arm. .........*'IType or pilot) Time Water Level Time Water Level I ... . .. ................................... real .................................................. ................ ............ ....... ........................... .......... .. elfair 1A ...... ............. Address.......:'............._'....... .. ................. ........ .... I.... ........ ............... ......... .... ........ ........ .......... ...................................... [Sipled].......... .............. Date Of tat I Bailer toss..... with 16.1t. drowdo" after........ Artwean now..................................... ......E.P=. Date........_........_....._...........__._.__... Ucense No.....0.7-97.............. Date.....2 . ..........• 19.. . a4 Temperature of water-.-... Was a chemical analysis made?Yet C3 No(jr WSE ADDITIONAL SHEETS IF NZCZSRABY) ecy 050-1-20 abm qrd No. W 100280 ; per"" WATER WELL REPORT UMQUEWMLRD.e AEA 964 Doperbeesma-,.RCceps—Owner'eOapy STATE OFWASHINGTON Water Right permit Na TMrd Cagy—IMBW's Cagy Dan LOU.— da.. yr�;rlaDdPTTui]zs 4TA 9R077 (1) OWNER: Nrrr (2) LOCATION OF WELL: caws MaQOII -$E—tN�_rNS�ccJSLT�_N,R _WM• (2M) STREET ADDRESS OF WELL IwnwrWew (3) PROPOSED USE: X opA1B5P0 Inasuul ❑ Mtrndpal ❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION ❑ De ftbr+ Wei ae m Ileavlbe by tobr.a mate,w,era tl meWwl aM unrde. erd show�diwee d Waaws ❑ DsWaler Too wea ❑ GIM1x ❑ eno w Nml arw n»Re d dw mebriw t•eeeh wrdwn peMbbd.weh w leew br entry la seas owp tl ipbrnWien. (4) TYPE OF WORK: I„w^m�°q"0en orina wall MUER" Fww To Abammrwd❑ New well ® Method:�0 EX dNen❑ omp rod ° Jailed❑ RKOnditgMd❑ retry❑ INamefw of-0 6 trtMs. (6) Dgm�NSKNIS:DRIkd—142 _teet ag Dh of OwO*wd wr 149 R. (6) CONSTRUCTION DETAILS: Dartq ntMaaed: 6_— Diem.Rom—4—rt.m 117 R _— yyetded O( Dbm,eom n.m a II TThsDM 0 Diem.tram+ -to__n' perlere0dfe: Yes❑ No Type d prtortlw u d 1n.ap in. a SIZE COpMf aw oren A prw-MM hwo h.to pedrehws bom ft to h. pwf0Miws ftm R.m------------- R' Salerls: Yee 50 w❑ MemdscWars NemO COO No. Type yecC wire wrap Model �0 117 Diem. �,Sw awe �ham Diem. _Smt SfaeMpsxgp: yes❑ No® Size dpreell Grew/paced ham n.m h. aurleae see . YM® w❑ To wflat depth' 1 R Meterbl used m tww Betonite Del arty wab w"n enuswe we w9 Yes❑ No TypedwMw? DWmd ebeb Nedmd d s"Bro wabae — (7) PUMP: ..., ulawmeis Name 14P Ttd'' wwesmtee 11 H1/98 .ta_ (6) WATER LEVELS: e� R. 0 .te. canpleted - - sbeobnl 94 R.b.lawmvd"°e Ibb WELL CONSTRUCTOR CERTIFICATION: Arbaen Meeblre bo.per uture nth Dab Anwen w her a wVbled by I o piiencled andll aooWshwq AWWI iftleyMR51 ror co StWWEcn 01 the isu am nd .v .ek. Opmpliarie wdh all YPallemtploR wMl CanshrlClldrl SWtdrdl.MtleriW used and we idormetlon spaded above ere true to my oral enoydedae end tenet. (9) WELL TESTS: Drawdmwr is amount wabr Tavel b mwO W bNw steed lnwl Was a pump Wt Mod.?Yes❑ No Q If Yes.by Wt m7 NAME Davis DMPSrilli eRro YqM: pd./min.wiN n.6awdown aMr ' Adyes Be air 8528 „ (sfanw)- utenw No. 0792 Rmvmy Etla Res blue w zero when pump WrMd OF)(weW U w val meured"M wal top mwsw bvtll water Leed Tarr weW I.evM Tone WOW I" Wane Conba='s Repishaten No. DAWT —( ir y9- (USE ADDITIONAL SHEETS IF NECESSARY) Dab or feel Beiw lest 1 6—aal.lmin.edm 10-_n o'ewdwn aft ---1—Ivs'in EcokW is an Equal Opportunity and Aftmalivo Action empbyer.For spa- Airwt gevmin.wM sum w at a W M' dal woommoda0on Reds.Colltad the Water Resourc0s Program at(206) Arweiw ew py.m. on" 407.6600.The TDD number is(2061407.6006. Twr4wstwm of wave_wee a ahomcd welyas Z;, Yn❑ NO M cry Rent•en 12AM••t