HomeMy WebLinkAboutBLD2023-00194 - BLD CD Environmental Health Review - 2/16/2023 �N,s, -,t MASON COUNTY COMMUNITY SERVICES Permit No: ?1.Oaoa3 HOC)f 9 y
�y e' PERMIT ASSISTANCE CENTER: - 7 r'I—I`,I r
• BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL „y,��L.{ rt/ L..•L0 TA
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0 615 W.Alder Street,Shelton,WA 98584 E% V
�` h ,• i) ENVIRONMENTAL
S f Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phort EB 6 LULJ
�iy� S Belfair.(360)275-4467•Phone Elma:(360)482.5269 I
tL N BUILDING PERMIT APP IJ$O�lder Street HEALTH
H
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME: ecc;(w/-•t C, /`ho.✓44S NAME:
MAILING ADDRESS: 300 t ;gla('n/vosek 10•-. MAILING ADDRESS:
CITY:5h i+on STATE:4,JA. ZIP:S'ff.5 gY CITY: STATE: ZIP:
PHONE#1: 60 -th'/-9716 PHONE: CELL:
PHONE#2: (v 0-S'S 0 - s335 9 EMAIL:
EMAIL: ....vha k y H-r<<n 6/(_ 5,7 c i I.W n1 L&I REG# EXP. /_/_
PRIMARY CONTACT: OWNERS CONTRACTOR 0 OTHER❑
NAME EMAIL
MAILING ADDRESS CITY STATE ZIP
PHONE CELL
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 22001 76 0 0 0.'0 ZONING
LEGAL DESCRIPTION(Abbreviated) FIRE DISTRICT
SITE ADDRESS S uM< AC i,n eii( a etd e'C5S CITY
DIRECTIONS TO SITE ADDRESS
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 14%: YES❑ NOg SNOW LOAD: zspsf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWLNG: (Check all that apply):
SALTWATER 0 LAKE 0 RIVER/CREEK❑ POND 0 WETLAND 0 SEASONAL RUNOFF 0 STREAM❑
TYPE OF WORK: NEW ADDITION 0 ALTERATION 0 REPAIR 0 OTHER 0
USE OF STRUCTURE(Residence,Garage,Commercial Bldg,Etc) Sh CIO
IS USE: PRIMARY SEASONAL 0 NUMBER OF BEDROOMS NUMBER OF BATHROOMS - .
HEATED STRUCTURE? YES(Whole Bldg)❑ I YES(Parris]of Bldg)iq NO❑
DESCRIBE WORK Met ( biA(idill5
SQUARE FOOTAGE:(proposed)
1ST FLOOR 2U00 sq.ft 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASEMENT sq.ft.
DECK _sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
GARAGE sq.ft. Attached❑ Detached 0 CARPORT sq.ft. Attached 0 Detached 0
MANUFACTURED HOME INFORMATION: *4 COPIES OF THE FLOOR PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERIAL NUMBER
ENVIRONMENTAL HEALTH:
SEWAGE/SEWER SOURCE: SEPTIC SEWER 0 / NEW X EXISTING 0
PLUMBING IN STRUCTURE? YES$ NO❑ If yes,attach completed Water Adequacy Form
PER METER/FOUNDATION DRAINS PROPOSED? YES 0 NOD EXISTING SQ.FT.
EXISTING BEDROOMS PROPOSED BEDROOMS TOTAL BEDROOMS
OWNER acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is by
signature below.I declare that I am the owner and I further declare that I am entitled to receive this permit and to do the work as proposed.I have
obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this project The owner or legal
representative,represents that the information provided is accurate and grants employees of Mason County access to the above described property
and structure(s)for review and inspection. This permit/application becomes null&void if work or authorized construction is not commenced within 180
days or if construction work is suspended for a period of 180 days.
PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT BPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
COUNTY CODE 14.08.42)
X —
Signature of OWNER(Must be signed by the OWNER) Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH 1)A ZI i 7/479 (Qni/i itc 15 Qdc(/'r(.
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1 Paint Ion)Mason Cdunty OMS I —1:
Thurston County Environmental Health
2000 Lakeridge Dr.SW 6 Olympia,WA 98502
360 867-2631
THURSTON COUNTY
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"" COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
22
l / c o AM
07 30 ❑Pl.t usu,1
I,torlh Day Year
Type of Water System(check only one box) M Private Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: �r.'i`1•;,Pt Iihcw y
Day Phone:( ) Cell Phone:( 3G0 )301 y71t;
E-mail: 5/t i/< 6!a�r,<s,I.lo,n Eve.Phone:( )
Send results to:(Print Nil name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name):
`(ho ,k5
Specific location or address where sample collected: Special instructions or comments:
/rri/r..l
Type of Sample(must check only one box of#1 through#4 listed below)
1.,Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total_Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total_Free
0 E.coli-GWR(AN)
❑Fecal-Surface.GM,springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes
❑Assessment Monitoring(AIP) Unsatisfactory routine collect date:
❑Other I 1
S
4.0 Sample Collected for Information Only -
Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
0 E.coli present ❑E.coli absent
No liform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC 0
Bacterial Density Results:Total Coliform_ /100m1. E.coli 1100m1.
Fecal Coliform 1100m1 Enterococci /100 ml.
Method Code:J SM 9223E ❑SM 9222D Date and Time Received: i `--
❑SM 9215B ❑Enterolert® 12-S-ZZ 1Z(S
Date and Time Analyzed: \ 7 - •ZZ Date Reported''
Samp:e Number(DC41 number plus five digas) Lab Use Only:
0 8 0 •� a1 5(�lare-CV
DOH Form N331.319(revised 01116)
Z j- <howle5 30 1 2 6-7
WATER WELL REPORT -.: 1 DEPARTMENT OF Notice of Intent No. WE50758
ECOLOGY Unique Ecology Well ID Tag No. BNV831
Type of Work: State of Washington
I] Corutrsretion Site Well Name(if more than one%sell):
❑ Decommission r- ' Original installation NOI No. Water Right Permit/Certificate No.
Proposed Um G Domestic 0 Industrial 0\lunicipat Property Owner Name Edwin Knowles
❑Dessatcring ❑Irrigation 0 Test Well ❑Other
Well Street Address 300 E Appaloosa Drive
Cunctruclion Type: Method:
El Ness•well U Alteration 0 Driven ❑Jetted 0 Cable Tool City Shelton County Mason
❑Dceperung U Other ❑Dug f]Air- 0 Mud-Rotary Tax Parcel No. 22001-76-00080
Dimensions: Diameter of boring 6 in,to 127 ft. Was a variance approved for this Dell? El Ycs 0 No
Depth ofcompleted well 127 n
If yes,what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
a I 0 6 in. 0 120 .025 in. IA I ❑ 0 I 0 Location(sec instructions on page 2): EA WWM or 0 EWM
O I 0 itt. — — in. ❑ I ❑ DIM SW Y.-11A of the SW ''A;Section 1 Township 20N Range 2W
O I 0 in. — — in. ❑ I ❑ O I
❑ I 0 in. in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345) 47.244201 N
Longitude(Example:-120.12345) -122.880481 w
L
a Perforations: 0 Yes Or No Type of perforator used
a Driller's Log/Construction or Decommission Procedure
>J No.of perforations_ Size of perforations_is by in.
Formation:Describe by color,character,size of material and structure,and the kind and
Perforated front R.to_ft b lose grown!surface nature of the material in each layer penetrated,with at least one entry for each change of
3 Screens: Yes U No E K-Packer ' Depth 118 ft information. Use additional sleets ifneeessary.
n Mannfrcnuer's Name Alloy Machine Works hlaterial Front To
Type Wire Wrapped slodclNo.
Diameter 5- Slot size.020 in.from 119 ft.to 124 ft. Brown gravelly medium sand,silty,tight,city - 0 44
• g Diameter Slot size in.front ft.to a. Brown medium clean sand,loose,dry 44 90
D Brown clay,hard,dry 90 91
Sand/Filter pack:U Yes Gl No Size of pack material in
Materials placed from R.to ft. Brown gravelly medium sand,loose,wet 91 101
Brown fine sandy silt,wet 101 112
Surface Seal: IC Yes ❑No To what depth? 19 tie ....-.
Brown gravelly fine to medium sand,wet active 112 125
Material used in seal Bentonite Chips
-- Did any strata contain unusable water? 0 Yes El No Black gravelly gray clay,hard,dry 125 127
5 type of water? Depth of strata
O Method of sealing strata off
Pump: Manufacturer's Name Type: -
D H.P. Pump intake depth: ft. Designed flow rate: gpm
a
D Water Levels: Laid-surface elevation above mean sea level 189 R.
v Stick-up of top of well casing 11=4 R.above ground surface
- Static water level 83 R.below top of well casing Date 11/23/22
✓ Artesian pressure_lbs.per square inch Date
- Artesian water is controlled by (cap,valve,etc.)
Well'tests:
Was a pumping test performed? E No ❑Yes r.> by shone?
- Yield gpm with ft.drawdown after hrs.
Yield gpm with ft.drawdown after hrs. s"' ., -,--. . ....... 1- Yield ppm with ft.drawdown after_hrs. w'>.
n Recoverydata(lime-zero when pumpis turned off-water level uncacured front well
y
Da top to water level)
Time Water level Time Water Level Time Water Level
J AN 2323 -
>r
a WA Stt4 -,; rat
Date of pumping test
Bailer test ppm with_R.drawdown after—hrs.
Air test 15 gpm with stem set at 105 ft.for 1 hrs. r. Date 11/23/22
Y Artesian flow gpm J
LI Temperature of water 52 ',F Was a chemical analysis made'? ❑Yes g)No Start Date 11/22/22 Completed Date 11/23/22
g. WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington\veil
3 construction standards.Materials used and the information reported above are true to my best knowledge and belief
y
J Driller U'trainee 0 Pei-Print Nitrite o ra Pby/thiaD-- Drilling Company Arcadia Drilling Inc.
Signature
Address PO Box 1790
License No. 2053 City,State,Zip Shelton,WA 98584
IF"I RAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.ARCADDI098K1 Date 11/23/22
ECY 050-1-20(Rev 09/13) If you creed this document in an alternate format,please call the Water Resources Program at 360-407-6572.
Persons with!rearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call877-833-6341.