HomeMy WebLinkAboutWAI2022-00137 - WAI Health Waiver - 12/9/2022 .' MASON COUNTY
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J COMMUNITY SERVICES
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,',, ,,.,,, Building,Planning,Environmental Health,Community Health
415 N 6`h 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 n N
Application for Waiver/Appeal D lJ L
Amount Paid: x 2,s DEC 0 9 2022
Receipt Number: Z `
Instructions By
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 Identification
Name of Applicant ANTHONY NGO Telephone
Mailing Address of Applicant 13851 NE NORTH SHORE ROAD
City BELFAIR State WA Zip 98528
12-digit Tax Parcel No. 3 2 2 2 7 --- 5 0 --- 0 0 0 0 2
Site Address SAME AS MAILING
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
O Separation 0 Food Sanitation Requirements
❑, Building Permit Review Policies 0 Group B Water System Regulations
0 Location, WAC 246-272A-0210 0 Water Adequacy Requirements
O Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
O Mason County Onsite Standards 0 Departmental Determinations
0 Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
CLASS A: SETBACK FROM TANKS TO WATER DOWN TO 25FT. TANKS WILL BE COATED W/WATER
PROOF BARRIER AND TESTED FOR LEAKS. MEET CLASS A REQUIREMENTS
CLASS A: SETBACK FROM DRAINFIELD TO APPLICANTS OWN WELL DOWN TO 50FT. DRAINFIELD WILL
MEET TLB, PRESSURE DIST.,TIMED DOSING,AND 24"+VERTICAL SEPARATION. MEETS CLASS A
REQUIREMENTS. WELL LOGS ATTACHEI
Applicant Signature: L-2 , �-, Date: ( 7� 9/2k
J:\EH Forms\Waiver-Appeal Mason County Local Revised I/20/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal Aaiver None required ss A -: Class B - Class C
,
2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/
Standard revision) 7 4(s_#),, A .Q?-1
3. Nature of Appeal: _
- cic b o w ✓-S . to 60
4. Hearing Official:
❑ Board of Health ❑ Health Officer
O Pollution Control hearing Board 0 Public Health Director
O Certified Contractor Review Board .✓a"'Environmental Health Manager
5. Mitigating Factors: -1 L
-- /t..414.5 twit i. to t ed *�`�"' f /Y,�_, le..
- flF at r......r c�' t tr Y v Li,,w.+••s t...tc31 i (,.-c.��
"45 at...:, 5,c-es clip fril:•Lit 1 n 6, 1---t C . IMO 1
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: C Date: I?"1`}a (i"a7"7'
PART 4: Deter i ation 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:
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: '1./" Date: LA-u/2 i
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC
Effective Date: July 1,2007 Revised April 2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations
Section I. I (completed by applicant)
Name: (1) Local Health Department/District (2)
ANTHONY NGO (see instructions)
Address: 13851 NE NORTH SHORE ROAD H t4,4_1*,,
BELFAIR WA 98528 'd'" (
5L-it . , A 1%bZA
Telephone: ( )
Signatur 7_ 9
Property Ideic€fication: (3) _ _
32227 50 00002
Section II. I (completed by applicant)
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
246-272A— 0210 50FT TANKS TO SHORELINE 25FT TANKS TO SHORELINE
Subsection: TABLE IV 100FT DF TO PRIVATE WELL 50FT DF TO PRIVATE WELL
Justification(mitigation measures to be provided): (7)
SEE ATTACHED. ALL CLASS A MITIGATION REQUIREMENTS MET.
Section III. I (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Conditions: (10)
Type of Waiver: (11) IQ.class A [ ]Class B [ ]Class C—Request DOH review before granting? Yes No_
Neighbor Notification: (12) Required? Yes_ No_ If needed, are agreements, easements, etc.properly filed? Yes _ No
Section IV. I (completed by health officer)
This Request For Waiver From State Regulations has been reviewed according to the provisions of Chapter 246-272A WAC On-Site
Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability
to provide public health protection at least equal to that provided by this chapter WAC.
[ ] Denied [i,Approved/Granted—Subject to all comments,conditions and requirements noted in Sections II and III.
Local Health Officer (13) Date: / /Z-o/L'✓
DOH 337-021 Page 26 of 32
The Well Log Data and Image are 'As Is' with NO Warranty. Well Log 1 s.; �o'-6 adel er:
3 Fi Q- 3° s>dn �No. W068271 •
WOK
�Co
and py
m
oeparbmsnt of Ecology WATER WELL REPORT UNIQUE WELL LD.I ACD 952
%cored Copy—Owners Copp STATE OF WASHINGTON
Thud Copy—onlleYa Copy • Wear Right Permit No.
-.a.;
. (1) OWNER: Name Don Parker mama 15005 191st Ave NE Woodinville. WA 98072
4) (2) LOCATION OF WELL: county, Mason • SE 1/4 NW hK sec 27 T. 22 N.R 3 wan.
IY . (2e) STREET aDORESSOF WELL(0,monestadbewl NE 13570 North Shore Rd Belfair, WA 98528
U {3) PROPOSED USE: C7 Q9 irrigDanestic industrial ❑ mun c (10)• WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
8°ort ' Test.Well C Ott"( ❑ Formation:Deserts by color.Maraca",ore at matarfet and structure.and mime fh4ienees of IgUfars
W Q De Water and eta Wild and roams of the meanies(if each stratum penetneed.Wei at hest one entry for each ,
t (4) TYPE OF WORK: Oenaq number a wed charge a hlornelion
(H mare than ore) MATERIAL i FROM TO• .
• _ Abandoned 0 New*NI cic Method:Dip❑ Bored C
O Deepened Q. • Cabe DO Drhen 0 .
Re0mndlionhad❑ Rotary a Jetted❑ Sand & gravel 0 6
O • {5) DIMENSIONS: Diemeterawet 6 inches.
Drilled 85 • feet. Oepthofcorpoetedwell 85 :t. Brown conglororate 6 17
• G
(8) CONSTRUCTION DETAILS: _h
ardpan ardpan 17 70
so-. Casing installed: 6 • •Morn from 0 it.to 80 t
Dian.trOm It to '
Le o • a ft. • R 'Sand & gravel with some water 70 73 •
co•4.▪ 4 Perforations: •Yes❑ No® Radish brown clay with gravel m 73 82
O .Type of perforator used • -
*"••• .. 'SIZE of perforations in. •
In- Sand & gravel with water 82 85
= perforations from ft.to ft.
CO• perforations from 1.to • ft.
v 4S perforations horn ft.to ft.
Q t;tryens: Yes Ldl - No 0 - c h -0 • Manufacturer's Name • COOK ` -
.0 Type stainless wire w_rap Model No.
Diem: 5 _stot sae 50 from ' 80 . R,l0 85 It, ' _
Dion. ;Slot size from h.to h. t
CD Gravel packed: Yes 0 No E - Size of gravel • .
. 1..
>L Gravel paced from • ft to ft .-
R is
Surface seal: Yes® No❑ To what depth? 1$ ft •Jt
H Materiel used In seal Be tonite .
Q Did any strata contain unusable water? Yea 0 No E .
v Z • Type of water? Depth of strata
) In - Method of seeing strata off • . .ts (7) PUMP: Manus urer'sName Jacuzzi _ - •
Type: Slit. Hf. k
.
• (8) WATER LEVELS: Wh0-801Paaftaverbn• wont seined 4/22/96 is. competed 4/30/96 .is_
•
WWI se
O reeve a levst a-
saes loved 6 R.below lop of••t or• WELL CONSTRUCTOR CERTIFICATION: .
V Animals*Masson La.per square rah Dale_-_
W Artesian water aconerAset>y _ • i Donslructed and)or accept responsibility for construction of Otis weft, and Its
W (Cap.vale.St.) compliance with at Washington weft construction stands/cis.Materials used and
O Abe informs on reported above are true to my beet knowledge and belief.
i, (9) WELL TS TES : Drltwd Ione
own a amount water level is red below stetic level
• Was a pump left made?Yea❑ .No® It yea,by whom? NAME Davis Dr1
• rt>li
CD Yeah gaLrmin..Me _R.drawrdown al tar•
hrs. (PeRa s OR OMri `ra aa0 r1c OR*MOM4-1 .. Address Belfair {JA 98528
to " • " - (signed) t—f CE� 4 License No. 2284
� Recovery data(tlrtrtla taken as zero when pump turned oR)(water Level rteaauredbon+wd �
top to water level)
O Time ' Water Levet . Time -water Level Time . Water Level Contractor's
m Registration nav 1 Sn111()na . Date ray• ,19 96
t • •
• _.--__ - • .(USE ADDITIONAL SHEETS IF NECESSARY)
Dale a WA
Bailer lest 10 pal.rnnin.with 70 ft dr.wdown altar 1 I"* •
Eulogy is an Equal opportunity and Affirmative Action emPloy • sPe'
For
Aineat gal/min.n.wih stem est at _ff.1x hrs.
Artesian flowg p.m., Dais chat accommodation needs,contact the Water Resources Program at(206)
407-6600.The TDD number is(208)407-6006.
Temperature of water N chime
lnr a er analysis made? Yes❑ No E. S
•
ECY 060.1-20(&B3).-I ^old• .0
•
fpnartmPnt of Frnlncly WPII I nn-Imane SvstAm
r
File Original1...irst Copy witif •" /`v
impartment ology a e G 1 S, WATER WELL REPORT Application No.
lecond Copy 'ner's Copy
third Cop @-'s Copy 7 a 9 9 STATE OF WASHINGTON Permit No. .... t„�e 3/t7
C t /
(1) OWNER: Name
. ` ., • c7-/.[.l.`.4.14,4) Address 3'2 C/ / -R /Q .-7- Sr. 1. 0C)fWe.-r0N, (4
:2) LOCATION OF WELL: county..../...,5 L�.-'?..•M.uY A....) „faro v7 l oT, 3. „ i,SetJ-7.... Tpv2. 2 1., R3 }�.
". 44/
• Searing and distance from section or subdivision corner b / /, , 63 4.a. ♦t" 1 .i't. k-1 nbtew A SVN
3) PROPOSED USE: Domestic N" Industrial 0 Municipal ❑ (10) WELL LOG:
E Irrigation 0 Test Well 0 Other 0 Formation:Describe by color,character,size of material and structure,and
show thickness of aquifers and the kind and nature of the material in each
stratum penetrated, with at least one entry for each change of formation.
4) TYPE OF WORK: Owner's number of well ..
(if more than one).... MATERIAL FROM TO
New well Method: Dug 0 Bored 0 tm
11 Deepened p Cable Q Driven 0
v� O ��
Reconditioned 0 Rotary 0 Jetted 0 /'Rvti. o,
5) DIMENSIO�7S / �A^ /�
�l Diameter of well 6 inches. 1/7 X-Let... ,44,,a f
Drilled a ft. Depth of completed well... 4........_......ft. .i.e.e,
O .6) CONSTRUCTION DETAILS: Or`....-I ct- �A71.--- a 7 a r_
4 Casing installed: " Diam. from ft. to ft. --
1— Threaded 0 " Diam. from ft. to ft.
O Welded.� 6......." Diam. from 4?�.._.... ft. toa.a" ft.
Perforations: Yes 0 No
Type of perforator used _.._...__......_.._...._...................
SIZE of perforations in. by ....._..._.._........_..__ in.
4 perforations from ...._.-----_.._...... ft. to ..._..._......_...... ft. -
O perforations from _..._ ft. to ._..._.. .._...... ft.
4 perforations from .--.___..._._:.. ft. to ft.
I
12 Screens: yes 0 No(1
BManufacturer's Name.._..._.._.__.
,Q Type..._..._.._..._._—_.---.._...._...-.__..--...... Model No
3 Diem. _.-____ Slot size from ft. to ft.
Diam. ...._... .._. Slot size from ....._..._.... ft. to _ ft.
▪ Gravel packed: Yes 0 No Size of gravel:
Gravel placed from ft. to ............_.._.-..-..._...._.. ft.
4 Surface seal: Yes] NooJ�TTl To what depth? ft.
Material used in seal....Li.[.'r MJt=
la Did any strata contain unusable water? Yes 0 No 0
Type of water? Depth of strata
Method of sealing strata off
a7) PUMP: Manufacturer's Name_.._ _.._.. .._..._._
Type' ...................................._..._..._.._..-_..._._.._._..._........HP_
8) WATER LEVELS: Laboveand-surfacemeansea l elevevel.ation
... St.
yt
tatic level ,,< ft. below top of well Datel0/ 2L
.rtesian pressure ____.._.-._........_...lbs. per square inch Date
Artesian water is controlled by
3 (Cap, valve, etc.)
u 9) WELL TESTS: Drawdown is amount water level is
lowered below static level Work started 19 Completed , 19_.._.._
K Vas a pump test made? Yes 0 No 0 If yes, by whom?
' • •leld: gal./min. with ft. drawdown after hrs WELL DRILLER'S STATEMENT:
.. This well was drilled under my jurisdiction and this report is
true to the best of my knowledge and belief.
r.
__ .ecoveryas data (time taken taso zero when pump turned off) (water level a://6)„,/, C�
` measured from well top to water level) NAME ,/y.4.4- '.
Time Water Level Time Water Level Time Water Level /� (Person,/so firm, or corporation) (Type or print)
Address-..1.., U F�-�0 X � �/ -�
ai
Date of test I [Signed]
alter test..cr��ll0 gal./min. with D ft. drawdown after../ hrs. (Well Driller)
.rtesian flow g.p.m. Date
'emperature of water Was a chemical analysis made? Yes 0 Now] License No Date , 19
(USE ADDITIONAL SHEETS IF NECESSARY)
S.F.No.7356—OS—(Rev.4-71). 3
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4)70
EXIST. 000 / -" `"k EXIST.
WELL ---\ /' / �. WELL
// I I EXIST. WELL
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EXCAVATION OF I RSp 1 I EXIST. I I i
HILLSIDE REQUIRED I j ,,,--- i I SHOP 1
FOR INSTALLATION 1 N
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I' / ` 75'-6"', /
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-----� , '
`` —y. . ----
/ 26' —r--
1 1 I . - --- -------
RESERVE - 24X50, 1200 FT2 _..... _ I \�
�.
\'' ----.L-------- Xi ISf.
5 BEDROOM PRIMARY Cy+ARAGE ''''
/ I
24X50, 1200 FP ;' I APPROXIMATE
_ I-- EXISTING ; // PROPOSED TANKS
--- HOME 1 / LOCATION 25FT+
APPROX. OHWM
I FROM WATER.
---
I
___--- - \
4 ‘.� �\ 1 CONCRETE TANKS
PUMP &ABANDON p-
I - -- I WI WATERPROOF
EXIST. TANK & PEAT EXIST. TANK - COATING REQ. IF
TIME OF INSTALLATION ' -------- EXIST. DRAINFIELD WITHIN 5OFTOF
WATER, SEE WAIVER
----
I _ --
'-I.,
W. .�
�' y w HOOD CANAL
4:`d"'"°... ,` I _
•
1t o' svo3n •:`, I
ROBEaTI vAYSae
1/i� t^•► -•• it ^t'd;
EXPIRES AN ASBUILT/INSTALL SIGNOFF FEE WILL
BE CHARGED AT TIME OF INSTALLATION
PIONEER DIGGING,
CUSTOMER: ANTHONY NGO TEST HOLE I: TEST HOLE 2:
INC. PARCEL# 3n27 50�0002 LS
No� FOUNp Np� FOUNp
SEPTIC DESIGNS ADDRFSS: 13851 NORTH SHORE RD
3083 E MASON BENSON RD. GRAI'EVIEw,WA 98546 DESIGNER ROBERT H.PAYSSE OVIDED
P O RSUE " �REN`DE ��A SURVEYS APPLICANT/COUNTY
SEPTIC
PURPOSES OFFICE-360-426-1803 FAX-360-427-2353DEPAR 1AENTlA6`ENCY REVIY E
W DESIGNER NOT RESPONSIBLE FOR SETBACKS UNRELATEEVELOPMENT MAY BE SUBTECT TO CYDER
O
SHEET: SITE PLAN SCALE !"=40' SEPTIC COMPONENTS.