HomeMy WebLinkAboutWAI2023-00050 - WAI Health Waiver - 5/19/2023 lApPt l 16 �3 O 00 5Z
�r MAY 1 9 2023
MASON COUNTY
1-) COMMUNITY SERVICES By_
Building,Planning,Environmental Health,Community Health
415 N 6th 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
Application for Waiver/Appeal
Amount Paid: � d .
Receipt Number: ,Z•.a ,3�Z
Instructions
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 SANTA SERVICES LLC Telephone 510-917-6952
Mailing Address of Applicant 2430 160TH AVE NE
City BELLEVUE State WA Zip 98008
12-digit Tax Parcel No. 3 q O 2- -- 3 I -- 0 0 0 .6 0
3571 SE LYNCH RD, SHELTON, WA. 98584
Site Address
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
o Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
O Separation 0 Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Location, WAC 246-272A-0210 0 Water Adequacy Requirements
O Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
REDUCE DISTANCE FROM DRAINFIELD TO PRIVATE WELL FROM 100' TO 90'
,z- -4 j 9'l
Applicant Signature: (../4 Lek.6Date: S `? 202/
PP 9 (&-yo-71)
J:\EH Fonns\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal (Vaiver . None required Class A Class B Class C
2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/
Standard revision) 246-272A-0210 TABLE IV
3. Nature of Appeal:
EDUCE DISTANCE FROM DRAINFIELD TO PRIVATE WELL FROM 100' TO 90'
4. Hearing Official:
❑ Board of Health 0 Health Officer
O Pollution Control hearing Board El Public Health Director
❑ Certified Contractor Review Board X Environmental Health Manager
5. Mitigating Factors:
HOME OWNERS WELL LOG SOWS AQUATARDS
NEIGHt3OK WELL LOGS SHOW AQUA I ANUS
WELL IS UvG1-<ADIENT OF DRAINFIELD
IVti ;rub y -r (9 5 C ev— t
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has be submitted. c�
Staff Signature: 6\.)
/l "q Date: � L —
PART 4: Determi ation of the Hearing Official
4 pi- 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:
4
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: L�/ Date: 1/4V Z)
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
‘41 7— -- 1. 3 BEDROOM RESI
DENCE
•
2. GARAGE
., 3. 1200 SEPTIC TANK
4. 1200 PUMP TANK
5. 1200 GALLON TRASH TANK
6. BNR 600 IN CONCRETE TANK
�'� ! 7. TRANSPORT LINE 2"
18. TRANSPORT LINES 1"
9. EXISTING WELL
10. WATER LINE
11. EXISTING BARN
, 17 `6, \ 12. PRIMARY DRAINFIELD OSCAR
13. RESERVE DRAINFIELD
4.AUDIOVISUAL ALARM
15. CLEAN OUTC.2)
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3 J KQ/A)brl��"i IN►• E AITE 1` '1 ' U
r� LIC ED DESIGN ` 1+
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l , �. ?.0as4-it— ann. SKr T v/ '
837
10.re Y 31
! '..:-.' 6-01
File Original and First Copy with WATER
WELL REPOR 'i"Card No.D`s6IL
Department of Ecology ...
Second Copy—Owner's Copy STATE OF WASHINGTON Water Right Permit Not
Third Copy—Drlllei s Copy
Address__-.,.
0 (1) OWNER: Name ,/�� Tc'-'—"' n �q
fy '}1! 1![�'L_tL S& _ saes-T.J_L N..R_.W.M.
a/ (2) LOCATION OF WELL County " 1 ^^�ram~
(2111) STREET ADDORESS OF WELL(or nearest address)
t9 (3) PROPOSED USE: �DomeeticIndustrial I] Municipal 0 (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
u) ❑ IrrigationF 1 ^
fA :1 peWatsr Teat Well Other Formation: Describe by color. character, size of material and structure, and show
thlekneet of aquifers and the kind and nature of the material In each stratum pan
with at{east one entry for each change of information.9-10 (4) TYPE OF WORK: li°m1eorratu^o�n.)1 w•q unTI mote ( To
13 Bored 0 4f9treaaA 41.rrft r 0 2.
O Abandoned J (Deepened O Method: ag �
Cable f-] Driven
= Reconditioned 0 Rotary[A� Jetted l] Blot. gp Clay � i ,�
0 8Lv� -
(6) DIMENSIONS: piameter of wall inches. t
E Drilled_WS-q---teat. Depth of completed well r S S•4 h. 6 61��1.191 � �j
w (e) CONSTRUCTION DETAILS: �!��
C Casing Installed: 6 •• MOM.from
l• n.lon.
Welded Diem.from —tt.to tt• 1
Thw readed
installed - DWI.from tt.to h•
...c
4.11
L. Perforations: Yes❑ Not -
0Type of perforator used
= SIZE of perforations
in.by C.
(0 perforations from
tt.lo- h'
.N perfaatbns Iron...--_
tt.to h
��'pperforalloonnai from a.tom—tt•
_______ r
,1
9 Screens: Yes0 Noll�S
ZManufadurer'aNarns —
4.r Type Model No.
-
Diem 9bt she_ barn H.to_ --ft. — -
y e from. ft.In _tt.
R
—
MAIM. Slot�• �/
>` Gravel pecked: YesU NoG-I glLa of gravel_
tt. III
I fin.
R Gravel placed from ft.to— 1 ``
To what depth?. H'
SuAaceseal: "akLT No� — I
O Did any
used in seal— fr�t -,�• -- 1
Z Did any strata contain unusable water? Yes�J No 1L/r - - r 1
Q-
(/) Type of writer? ---Depth of sluts - _ Cyr - �"
OMethod of meeting strata off - _--_(I —'_ i--�-'- —
13 (7) PUMP: Manufacturer's Name
rt.P. — —
� Type. ---�
0above rfans elevation h.
_ (8) WATER LEVELS:�� above mean rise level ^
o Static level— t�b n.below top of well Dates 2y — _- -
WArtesian pressure- lbs.per squvs tech Date�---- - -- /1 i __
y-- Artesian water is controlled by— (Cap.valve.«o.)) �+—�-V ,19. Completed 7+14 7I —,ig —
Work started
0
e+ (9) WELL. TESTS: Drawd le amount winter level fin bursted Dhow etanc IwN WELL CONSTRUCTOR CERTIFICATION:
C Wes a pump test made?YesLI Noll n yes,bywhom?,
Qj n.drawdownsHN hrs. I constructed sndror accept responsibility for construction of this well•
E - - Yield: gal. with '
and its compliance with all Washington well construction standards.
y,a •• -. - .-- •. Materials used and the information reported above are true to my best
L knowledge and belief.
QRecovery data(time taken sip zero when pump turned on)(water level measured /
CD from well top 10 writer level) tune Water Leval Time Water Lbsl B ) r r Zt�C
Q Time Winer Level NAME- ' Ie s J Ranow) trIPE DR PRINT)
/y (PERSON.RAM.Oft
- -_ —" Address-f'O 4� 7 rift At I
IPMZ
~ Mateo!test i aa.e _ _LicenseNo._nr`
- (Signed)jtee, nalel»
Bailer test h gal./min.with ft.drawdown stet _hre. Contractor's
Airiest_a,LL_gsl.lmin.with stem fat at ISO H•to-- --•^'hra. Regis4
No.
Date^Pi- -, 1a
Artesian How-- g.p.m. Cate— �-•�
Temperature of water_-Wee a chemical analysis made? Veep No0 (USE ADDITIONAL SHEETS IF NECESSARY) 0
ECY050.i-20 (i0107) rate- ' •
W•
ELL REPORT Start Card No..0€FS:6 T
File rtm Original and Ecology
Copy with WATER UNIQUE WELL I.D.
Department of Ecob9y
Second Copy-Owner's Copy STATE OF WASHINGTON Water Right Pa(rnit No.
TTird Copy-Ortller'e Copy
L
(1) OWNER: Name 1:1-- e`ni-e rSem Addreae— y ,q ,
0.1
(2) LOCATION OF WELL: County- aL�"1L+t3
_CL
t 1 t_/V'1
(4e) STREET ADODRESS OF WELL(or nearest address)._
X
0 irDrigationomeatiC Industrial Municipal❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
(3) PROPOSED USE: show
Teat Well C Other Formation: Describe by cobr, character, size of materiel and structure. and
�nfed
N I I peWatAr thickness of aquifer;and the kind and nature of the material in each stratum p
Ownsr'e numtrK of welt with at{east one entry for each change of information. FROM TO
sa (4) TYPE OF WORK: (it more then one) --' MATERIAL
X Method: Dug ( I Bored Cl A���fi C
Abandoned❑ New wall Cable 21 Driven C 4- 9 l
C Reconditioned
I ltt. Li 46
2�?' IT :::: ;;t1:
codwellSi
• (6) •
�U ft.to „.from—
W Welded itil ' Diem.from- ���� _ q
t Liner installed 0 _ ', Diem.from —ft.to— ---n• _ ,/� ,, !
Threaded ❑ 1— LILT/5 _ 4rJ/ /
s- Perforation*: Yes�l') NOD �Je'r•`r �-"� [y U /�/ f ��
O Type of perforator used. , r, - _
_ -in ,ri sew
In.by _ r tea„ G.MI /_,_
SIZE of perloratlons__- -,ft. � • a
C perforetbnafom_- -e.to---
RI — tt.to_- —ft. _�
CC _ perforations from — — -
er n.to!— -ft. J
CU �_p{ertoratbn - _ ----
O Screens: Y..e t10 /ri- --- `
—
CU
eC Manufacturer'eName_
Uodat No.�
+„a Type e n,".T - - --7
I� .��/ from S ft.t0 ft• -
� Dlam. �--Slot size-
/ �"'- - -- .
_trap- --ft.to_——ft
CDiem._ -- t size. __,''.,..
l` Gravel pecked: Yost ►b[She of gravel - -- f -
L -tt. _-
(Q ft.to-
-Onvel placed trompT- _ —_
To what depth?��—tt
�, Surface*fast: Y _ --
O Material used In seal. G/y0/ /3("-T
Z Did any strata contain unusable water? yes piX5
pth of straw—- --- - -'
0 Type or water? _ �j��j,� �_
M«hod o1 seatfnp etrata oil -— `�-[�-X-t/
'Q (7) PUMP: Manufacturer's Name.
`Jh ? —H.P.— - -
CO yea. —.. —
Lead-ewfsoa Nevatton //0 _ tt. —
� (8) WATER LEVELS: ±abova mean ass Iewt— ! - — -- — -
O static lave! - ->2 tt.below top of well Oats
W Artesian preaattrs_ _ __lbs.par/quire inch Date —
AReelan water is controlled by- wive.ate.T -— ` ;_4i .19. Completed 19 �
rH —
Work•caned3
,e,, (9) WELL TESTS: Drawd wn le ern Ant water level is lowered below static taws WELL CONSTRUCTOR CERTIFICATION:
Was a pump test made?Yes NoLJ It yes,by whom?_ -r
Q, —ft.drawdown after �• I constructed and/or accept responsibility for construction of this well,
Yield:E - gal./min. " __ e
and Its compliance with all Washington well construClion standards.
., Materials used and the information reported above are true to my beat
tL _ knowledge and belief.
(Q Recovery data(time taken es zero when pump turned ott)(water level measured /�S
GI front well top to water level) Water Level �G.��?�p/���"G� /1 J ��/�n"
® Time Water Level Time water Level TWO - NAM rTYPE CM PRINT)
C SON FIRM,,OR CORPORA / M PRIM 1
a) - - -- — --vC
Address/ 2 7 Di 4 i' ' �rOf' _aktil
azia
-- Date of test -- (Signed}_ _License No.� Ilit
Beiler feet a
� (WEII.no
of1 �_ft.drawdown after _bra. _
gal./min.with Contractor's `
S.for ►ire• Re ' tion 41 r v _,19_
Aimee*_ _oat/rain.with stem set at- --- Re Date
- r1
Artesian flow—--- palm Date
I J NoUr.,
Temperature of water- Was a chemical anayaie made? Ves I LJ (USE ADDITIONAL SHEETS IF NECESSARY)
ECY0th>1.20 (10197) -lase' r9•Ts�-'•.t,-•+a
4.3
16 Ys. ..
O. rr
( ( STATE OF WASHINGTd►.
OC Appli. # 8402 DEPARTMENT OF CONSERVATION
Zii •
. Permit # 7915 AND DEVELOPMENT V S
WELL LOG . No... 19 ../ 3 W_ 2M......'
N 1.•:,Part.;.- August. ... I96-7 r — '— -- - .
Record by...11.DLt1Ier....._.__. I } ��'., .
C Same Dliltet.4S..I> O!` • .. t • 1 t i
C . L cation: State of WASffiNGTON• W _ _4_it._ _ _ .•.. •
0 47/ 1 Co tY. ..._mason - , t 1
.. ..• 1 11r� --+e-LT_% see
� _. ..IK °tag am of Section i ..-
l. . .__ ec2 Tl�r, w:. $
- DOlino Co....�.§.5..g ._4.l..priltimy._a =_ 1�_..- 'r,,i,
s -- _--.,-Addre _P t -g9X. ' .$tL1ton_f1W.ashi.tiiton..�__ • • t..r.,•
;.. ems or nor_ able- Da .:.M:ay... labi7_� r.
owe._ _Maspn-.CowInty.,El;e;II 4t,=(t-{S.pg. ;.:__�.,, ..---_.t,, •
__ --• 1 :Aware... Calker S.iv.2. .7.-]4.-Ridgerp*d.51 ,,.�.h .lean.,-11Y •
tQ �. _ . - tabove : - 1 i -
24 - datum. -=, _ T•_rr n.�...--
1 T.11IcIKMaaa Dsruf ^'
�.._.. _. ..]lwTRtan - ._ --;ry.._ _(WV. _liar)
ice.+ - '('Tranaeeibe driMet+a*mansion,Most*bat roarspiTrisrldittewsalt9.11t-D rthesil..
-i U material water-bartng,so seat and mord*tittle level if reported. Girl depths in feet
A }sios►.laodrerfar�datum.autlae otlrr rla.Jadlsafd...Goertia.-w4 t tfe4ig+•*P C-eelumb.- .
y,t �- - u fiasibls Following log of materials,list ail easing*,perfosationa:Scrotal.etc-) `
y , --,
- , _:lig . .
i Fill1 3
1 Graveiclay and sand '. ' 30
--- ....:� gravel . clay and sand ... 3 62
H Sand ... 6 •74
. .• 1.. —�mardpanf blue F 74 100'
en -- . ....elay,'bIue • 100 135 :
•
o - -y • , clay;61ue;4hard ' -135 180', ;
_�... -�C1ay,�l'ue • - i 180 1901 ..;
>. - . ---_._ _ __ -.C1ay;liTde'aril sand •• 190 233
o --- firavei and-sarid - _ - 233^' 247- Y- .
o -using: 8*' rirn I 4I1 1 ,
v -- - 'Yietd ..10Cr gpm 'rest made fl lay 117 ! 1967
w
o - ..... i__.; hump:. It_t.pl.: sub._ Myers , ':.) . r r-m- . ,
.
,-:, xpin up ---
Isa,tO Street.—__:.ott. sheets..41
t
l
. iv-e,� ti box- i