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HomeMy WebLinkAboutWAT Application - 12/10/1998 MASON COUNTY DEPARTMENT OF HEALTH SERVICES ���,,•t,�,t ��� Environmental Health Water Quality Personal Health PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 BELFAIR(360)275-4467&4468 Application for Determination of Adequacy TOLL FREE 1-800-562-5628 pP FAX(360)427-7798 Instructions 1. Complete Part 1 Rio determination.can be.made Until Part I is ,y Coi ipleted: 2 Complete only the portion of Part 2.applying to the type of water ysteu utilized 3. Submit completed application,with attachments to the health department for review: PART 1: Applicant/Parcel Identification Name of Applicant' 1,A N�. Date / /0-9� , Mailing Address (p5�1 P e- 0-5 w i -4 Telephone --4e7-61 13ct-14-1 e, Cofti idd W A t B O9l Assessor's Parcel Number '�J'. •Oi Type of Water System (Check One): Reason or A lication Check One : ❑ Public/Community Water System(2 or more Building permit connections) 0 Land use application,if so.. Individual water source(one connection),if so.. ❑ Division of land Well #of Parcels? ❑ Spring/surface water SPH9 - ❑ Other(explain) 0 Boundary line adjustment ❑ Other(explain) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adequacy: Public Water System Name of Water System — Water Facility Inventory (WFI)Number: ❑ The water purveyor has filed a letter granting blanket hookups to this water system. ❑ I am the manager of this water system. The water system has been approved for services. There are presently connections m use. This will be the connection. This water system is able and willing to provide water to this(these)connections without exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date W-7 H:IWDATAIARCHIVEIWA7'RAD3.WP Update:October20,1995 Individual Water Well Water well report(attach to application) Depth e / ft. ❑ Well capacity test(attach to application) / gpm gpd Well capacity tests are often performed by the well driller at the time the well is constructed. Test results from these tests are noted on the water well report. Results from these tests will be accepted. If the water well report cannot be located by the applicant or if the water well report does not have a capacity test,a well capacity test, which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. t1/ Satisfactory bacteriological test(attach to application) Individual S rin /Sur ace Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ I have reason to believe that this water source can provide at least 800 gallons per day and/or provides water at a rate of 2 gallons per minute based on the following observations. AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT In addition to providing the above statement, the applicant will need to arrange an on-site inspection by the health department prior to determination of adequacy. Departmental use only. Do not write below this line. PART 3: Health Department Evaluation (Staff Use Only) ❑ SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet the needs of its intended use. This determination does not address adequacy of the distribution system, guarantee an adequate supply of water indefinitely into the future, or guarantee compliance with all applicable WDOE water resource regulations. ❑ UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason (s): c REVIEWER'S SIGNATURE 01, DAT)✓ � �1� j Icf H:IWDATAIARCHIVEIWATERAD3.WP Update:October 20, 1995 Diagram of well number: 57796 t 1 = Casing ( ) = Hole - - = Screen ! ! = Perforation ORMATION DESCRIPTION DEPTH COMMENTS Surface 2 ;ANDY BROWN CLAY GRAVEL 19 /\/\/\/ Static Level DROWN COURSE SAND GRAVEL & WATER 39 76 - - 77 - - 79 - - 82 - - Completion ROWN CLAY 87 Drilled To RESTHA VEN HOMEOWNERS ASSOCIATION LAKE NAHWATZEL SHELTON WASHINGTON June 12,2001 L.H. Rosevear Resthaven Homeowners Association Group B Water System Re: Permission to encroach on 100'radius of well on property to lot#6 of Resthaven Subdivision, Assessor's Parcel #52008-54-00006. To Mason County Department of Health Services: This letter serves to verify that Resthaven Homeowners'Association,owner of the Group B Water System ID#WFI 719600, hereby grant permission to Arland and Linnea Wallin,owners of lot#6 to construct a garage on said lot within 66' of the well. This garage is to be unplumbed with no floor drains and not to be used for the storage of chemicals. Sincerely, AWRENCE H. ROSEVEAR,PRESIDENT DATE SIGNATURE GUARANTEED EDALLION GUARANTEED /1.EY�' K A .) AL ASSzCCIAT;o ( WA94 ; X9004108 S C I)M!'eIFS P°.:).•1AV ve/f MASON COUNTY / DEPARTMENT OF HEALTH SERVICES ,11 Environmental Health Pert, ,. 'ea lh 4 PO BOX 1666 SHELTON,WA 98584 LOCAL(360)427-9670 FAX 3 4 - 798 Application for Waiver/Ap i '•'; E@Eil n 66 V /��� , Amount Paid: —' Receipt Number: /(0 1 '2 9 Instructions PJ-'t ITASSISTANtE CF.M_S ..,.:.., n.f.Y.. ..:..:......::..... .N;: ... ..t�::.t�:f%fir'.:i i:.::�:.i:.......:.�. A:'•y!:: j;. f<•yv{2:.'yi: \"'ifyi:;:>�ii'v•y'�i�::ii'� i:to"; �:'a'! f`�:y' 1• :y9`py: T.:C:y`.v�:.`: . . ;y. €A:'j�•..;;�i rA'.c ':sc`'. A ' 4:. <�.„: •$ ..¢R t..d::< c.2.,., > • •�SWP�:.:,: �i:ia•?�,'•..,`'''''.' :a �i;c�ii::.'G3'•:%y:: . ..;y%:r.i:.�i:'iri,?xJ`: .;r':i::•'y>sy:Ls� i:G .yl-^.ii:':i'6R �.2i:.v,•.2�a�z:.<.n +�<. �4::: .; �•'��:6: .,S ....:`&(f,�.f•<,'g.;.,..:.,� ..::;3y:..,.;c. " • � + ;y+ �T??. ' fJ'�y�;��Y+.f'aE: ..:.:�. tted.s A�tt1 �ttth;6iizichtnentsta. e:h�a t�c�a PART 1: Applicant/Parcel Identification Name of Applicant A fZ LAt)C) Wcat tV Date 5I1 S /0 Mailing Address Zt) UJ O I yy), P' - v. d4-. Telephone -/2(0' //?? S` ^i , l.,JJ 7, 0$ f Assessor's Parcel Number Jam' 2. OO ._5 L/_ C30(,) Subdivision Name and Lot REST-I-htlfry Ltt- Pro 1 (o • Sysitv., 1'Rc s i►nn,c,,.� PART 2: Nature of Waiver/Appeal i o �,,,F z ►7Ie16,oc 0 On-Site Sewage Requirements O Food Sanitation Requirements o Building permit review policies ❑ Solid Waste Requirements • Location, WAC 246-272-09501 Group B Water System Requirements o Holding tank WAC 246-272-12501 l7 Water Adequacy Requirements o On-Site Standards 0 Enforcement Timelines o Certification contractor(pumper, 0 Departmental Determinations designer, installer, O&M spec)requirements D Other Description of Waiver/Appeal(include justification,additional material may be attached): I1 W2 11Wo►=t I k pti-rr sro/., -b crow-ILon - •too'r caws OF 4.. Wets oiv ►td " lux. t (o-Mi4N t.ucuA l b- lbetk. -�'*o... l Orirrtnti toc Jta. Qt �✓PO✓-; -NA- Vat Accorq. Wt. hate vr.sia.rcA..A wait l oe�s j .44& Ant" 1q, -ZuA6 fk a ra1-1 Pave i F CIII46 LW ' 1.4s 44 pro"44 A"4w .-t Pe°4 +0^J b•►.yand 44.t. 1S' A14d4L (. Af'rrtt oN Si k Rat c410L41(30.1 LOC COVAd knd .Jose a [. (,ALS D 4..40a w►•cla44i. 601 brick -p L ori Qwno4 14 Si-waWS l 4 0*-44.4.sick. ReS iwt S Air .CAtt 1 oe 4&t parr.e-P.1 - 4%vL Ste. s, P�.., Foti. t ex"4t ati ern ti drs LAA-4 s Oa Pr°Pe$<d 9s�g e• Applicant Signature: &IL.- Date: S7L, 1 rd eca q'L?- yyyo 9.9o- O3Zy 02MR) K) S kuP J 0l4 2 d H:IWDATAURCHWE1WAIVFRWP update:November 23.199S PART 3: Health Department Evaluation (Staff Use Only) IA. Type of Determination.equlred: 1B. Type of On-Site Waiver(if applicable): 0 Appeal Waiver ❑None required Cl Class A ❑Class B ❑Class C 2. Identificaton of Specific Code/Standard/Determination(include date of determination or latest code/standard revision): �iNC 2L � 29 3. Nature of Appeal: tick�Y,cl� L,.)r.:V Lf �nr VY\pL)VbtcA Cr fC&3f 4o br+_ OD fro•,-, vsk 11 con Gre,,-) 6 LAY/Aw ads-tr_ 4. __..- Hearing Official: ❑ Board of Health /Health Officer ❑ Pollution Control Hearing Board ❑ Health Services Director ❑ Certified Contractor Review Board ❑ Environmental Health Manager 5 Mitigating Factors: lUn�1u4-0:3cc,l 4(C C � . s0b1s�.n(�c,1 ,I �„f,.y,.s r►stirs 11e) well I�ax A '� G✓K� app(0 JG t .Thal C'.c3vKl�`�J(,.,5 . M -Ow r- I.l rG.V, ,\- _ �e - LAJc4 i `..5, n.,)v-,Q.r' znc c.ci-, . 6. I have reviewed this waiver/variance request. It is complete,and mitigation required by state and local policy has been submitted. Staff: ,�'1• Ci- i� Date: 6/6/o / 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: Gar _ tL 13 The hearing official has determined that approval of this request could potentially have an adversely affect public health and is hereby denied. This decision is based on the following findings: Hearing Official _ - , `' Date: c, YAWs::y•Gi ifl i%�ii{F3.l�Vtl4liW.LJ .»o RESTHA VEN HOMEOWNERS ASSOCIATION LAKE NAHWA TZEL SHELTON WASHINGTON June 12,2001 L.H. Rosevear Resthaven Homeowners Association Group B Water System Re: Permission to encroach on 100'radius of well on property to lot#6 of Resthaven Subdivision, Assessor's Parcel#52008-54-00006. To Mason County Department of l lealth Services: • This letter serves to verify that Resthaven Homeowners'Association,owner of the Group B Water System ID#WFI 719600,hereby grant permission to Arland and Linnea Wallin,owners of lot#6 to construct a garage on said lot within 66'of the well. This garage is to be unplumbed with no floor drains and not to be used for the storage of chemicals. Sincerely, / � ., ' C-- is , © / AWRENCE H. ROSEVEAR,PRESIDENT DATE SIGNATURE CUARANTE Li) EDALLION GUARANTEED . EY:° K A J AL AS P. KCCIAT:O tWA94 ; XU0^ 4108 4 • MASON COUNTY DEPARTMENT OF HEALTH SERVICES • ingropiwpo,�� Environmental Health Per:, ' • ih PO box 1666 SHEL 0 4,WA 98584 LOCAL(360)427-9670 FAX 3 498 Application for Waiver/Apo',!, E@E 0 / � l Amount Paid: ��(, ►' .`% , , Receipt Number: Ho 7 7-9 Instructions PloitTASSISfAI VA: • /+���k �Qj7 t� �{ I��3• o' � � }►ryy�.�A... �< ..,d�.,+`$ka.d:}: ':S2'<:$:c'i^v: :.<'n'-:,33 +,:`Tf'• xl{Y .t1. X�. i1[.1f,. �v. . �Y.. }:3.}. � .:.. �.Y.,I •.Yv.r ,t .d;c:.;4•n:i:::n.y+:.d; ;:;}¢ u .'�•+.'ic i ''45:'",:::yy.::..;;:'rl';, n: ':$.S�:.a,.';::wo-:::f5r:.< .Y g..h i� y .� }.c.}::..:::.::...,}::><:�2::: 3. sA>: 41116.00 ith attachments to tie:hea�lt depart me t fo Y CW. .w>:k: f<:s,,:: }< :<,}. PART 1: Applicant/Parcel Identification Name of Applicant AR L AO 1) W N Date 5/1 g Jo 1 Mailing Address ZO LO d 11(m P' - tip (It. Telephone 1/2(- 7/F? '•% , L4 yes g y Assessor's Parcel Number 5 OOk ._SL/- Q7 b off, • Subdivision Name and Lot ReST-/1kIfry L-r K)D . G Sysk,-. - 1Ztst e_.-_) PART 2: Nature of Waiver/Appeal t o t,a FZ 71g1 (ooc' 0 On-Site Sewage Requirements ❑ Food Sanitation Requirements cl Building permit review policies ❑ Solid Waste Requirements El Location, WAC 246-272-09501 Group B Water System Requirements 0 Holding tank WAC 246-272-12501 ❑ Water Adequacy Requirements o On-Site Standards ❑ Enforcement Timelines 0 Certification contractor(pumper, ❑ Departmental Determinations designer, installer, Oct Mspec)requirements ❑ Other tio(o' Vi -,i4V4.-E Description of Waiver/Appeal(include justification,additional material may be attached): Wou-tii 111114_ VI'mrsStory -}o e',K ci'o On 44- too'r4c vS OF- . 4k w,e/.. BN 44t A d,004 4' t(CLQ. � nt 1 oC.Mi ON t cu.1 d be- beck. 4�l. or ic�t n t o itim pc 41.1. ear po✓4 4 4to.4- t4,11 dauu i. Wt. ho.vt YeStei wt LL lords i r•44,e h.-- Ail a k New►d j,s tm p e- C1044 t.21;,ct, wed p.vVidie rtddiJ+o.14 pro44Owl bayandJL. 4. ici 12' Sul- S,u_ Pic{ fkf'Tfit ON 5 c,w•atON we, CA4,4d Xrnd tinn.SD4& t-'4oF 44 n,.41441.. 6`4 c 4J e, 4k Skit. Ra.SN�'t t PIMA- IS Sivbia A+r .i Call pi� po tt..Q.' t,Easc Su- S i pl t..i Fay l ecw4i ors An d dts jLA"s Or P+-a Pc sad C Ky c, Applicant Signature: ( e Date: 5/2- Co,✓ 1gz9— ("WO r 99o— o3L if 020 S 0l9 2 H:tWDATAURCHIVEIWAWERWP update:November 23,19911 PART 3: Health Department Evaluation (Staff Use Only) IA.Type of Determination.equlred: 1 B. Type of On-Site Waiver(if applicable): 0 Appeal Waiver 0 None required 0 Class A CI Class B 0 Class C 2. Identificaton of Specific Code/Standard/Determination(include date of determination or latest code/standard revisio ): W c 2% 29 3. Nature of Appeal: l(rrvv ,Y,cl6, Wc.,v t.'I {� v plue,-tbtul qr rc4c 4o be_ r Etc�•� vJt 11 or. G coo ['� L.}L.�w +ckr-tc. 4. Hearing Official: ❑ Board of Health /Health Officer ❑ Pollution Control Hearing Board 0 Health Services Director 0 Certified Contractor Review Board 0 Environmental Health Manager 5 Mitigating Factors: L,n)tJ.-,b (Ar.4rc, t. • 5'ubs-k,r,c�0.1 . ICj t.JCI�• ex.s, �c, appro✓c.I Colnc4,l;ov : NQ *Ica r (Arc, .Y-. cf. N10 e.11.C 41 'i1Q xArjes f1 or,v '.c �j �t'.f�^•,;S Sa•, fro (jJ r `..5J4C.v, CS�.J�,2r A A V 2✓, �Jcci]c4c,1 6. I have reviewed this waiver/variance request. It is complete, and mitigation required by state and local policy has been submitted. Sta '1 ( Dab: G G 11 PART 4: Determination of the Hearing Official Ar( 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 have an adversely affect public health and is hereby denied. This decision is based on the following findings: Hearing Official _- . . � �" fl � bate: t /7()/ N•! lr4E RC.H.W1=R,......� .. .. __ ....._