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HomeMy WebLinkAboutWAI2023-00080 - WAI Health Waiver - 8/8/2023 (2) 415 N 6TH STREET,SHELTON,WA 98584 MASON COUNTY SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 NORTHWEST LOGGING 2522 N PROCTOR ST#15 TACOMA, WA 98406 Applicant: NORTHWEST LOGGING Parcel Owner: MARKLE SUSAN L Site Address: 26132 NE North Shore Rd Primary Parcel Number: 323332300020 Waiver Request Number: WAI2023-00080 Waiver Description: Other Waiver Submitted Date: 08/08/2023 Waiver Review Date: ?atm23 Waiver Status: jp/'pv2Cf If you have questions or concerns let us know. Sincere , David Anderson 360-427-9670 Ext.353 danderson@masoncountywa.gov 415 N. 6th STREET, SHELTON WA 98584 MASON COUNTY SHELTON: 360-427-9670,e;:t 400 CMti l 1 SERVICES BELFAIR:360-275-4467,ext.400 Ilding,Planning,EnvtronrnentaI Health,CommunityHealth ELMA:360 482 5769, ex .400 FAX:360-427-7798 Application for Waiver or Appeal /1CM.117MIM 10 . C-v ,,-Ajnoun -ald: C�`Z� Receipt Number: 0 —3 Q� .,,, � �Et AUG t 2i,,3 WAI o��.j - O CC) C�U BY_-----------` Instructions: WI l oc Jn J Oil norw 3 z 3 3'3` Z Z_ (lotto 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 Information Name of Applicant V Q 1 \AJP - LC 99 jT Telephone 3 (. -BO/^7 3 -is— Mailing J�J Mailing Address City -T0\ CC)Y7 \ � State Vu 1 Zip I B 'IOCU Parcel No. 3 2. 2 _`) _ Z z -- Q (? Z c Site Address '2 / 3 Z N N . 5ho Subdivision Name and Lot f..Ch 2r 34 - /1 F, T`U*_ &ovrLcrtss 4cf/zg, sLi/y PART 2: Nature of Waiver/Appeal ❑ Onsite: Class A Waiver ❑ Food Sanitation Requirements ❑ Onsite: Class B Waiver ti Group B Water System Regula'iors O Onsite: Class C Waiver tyi Water Adequacy Requirements ❑ Onsite: Location, WAC246-272A-0210 ❑ Building Permit: EH Review Policies ❑ Onsite: Holding Tank, WAC246-272A- 0 Appeal: Enforcement Timelines 0240 0 Appeal: Departmental Determinations O Onsite: Contractor Certification ❑ Other Requirements, Description of Waiver/Appeal (include justification, additional material may be attached.): ���� I L GP\')N cSuLsi OOS �Y act Ropoi I o, 2,-rav-(1,- mcisOn_ Applicant Signature: Date: `2-7 ?j Revised 8/13/2018 This form may be scanned and available for public view on the Mason County Web site. l'age I of 2 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver (if applicable) Appeal 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) 3. Natur of Appeal: ReJoce, ivojer adeyua c vi reme lts fir' a io-P orl t fya1n !doo ypd to lYYb"'pJ 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board ❑ Environmental Health Manager 5. Mitigating Factors: Cam de5/r( rPQL 'eme4i 5 rtrm ooK Q/'fO( al0ac4 //'f down fo 350 p vr c f ri ( 5ooyd 10100. 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: Date: Y/2//207) PART 4: Determination of the Hearing Official #17 The hearing official has determined that approval of this request will not adversely affect public health and is hereby granted. This cision is based on the following findings and condit ns: 7'0go,- r�� C'.� ru c-i'in l Jy%vIffrvolre4ceLcwyy, v ,it .f /LQ t ❑ 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 9 Official Signature: �I Date: J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 2 of 2 arNIMrr► I SLR 2..c z -0031 e + 2199912 MASON CO WA s + 07/24J2023 02:08 PM DE9068 Roc CL V IIIIIIIIIllIIIIIII.III1liiIIIm11III1Nlllillld 6.50 Pages: 4 JUL 2 6 2023 rit----io '-' ! RECEIVED JUL 2 4 Z023 it, t _J \..... Return to: Northwest Logging Company, LLC 1 2522 N Proctor St.#15 Tacoma, WA 98406 DECLARATION OF WATER USE AGREEMENT LDB #1 Water System This declaration made and entered into by property owners: GRANTOR: Northwest Logging Company,LLC With users: GRANTEE: Northwest Logging Company, LLC PCL 1 OF BLA#18-04 AF#2090193 \PTN OF GOVT LOT 1 S 44/28, S 45/4,Parcel#32333- • 22-00030 PCL 2 OF BLA#18-04 AF#2090193 PTN OF GOVT LOT 1 S 44/28, S 45/4, Parcel#32333- 23-00020 LOT 4 OF SP#3120 AF #2092412 PTN OF G.L. 1 IN SEC 32& 33, Parcel # 32333-22-90140 Township 23 N, Section 33, R3W,NW '/4 of the NW '/a • The property owners hold title to certain properties situated in Mason County, Washington described as follows: PCL 1 OF BLA#18-04 AF#2090193 \PTN OF GOVT LOT 1 S 44/28, S 45/4, Parcel#32333- 22-00030 PCL 2 OF BLA#18-04 AF#2090193 PTN OF GOVT LOT 1 S 44/28, S 45/4,Parcel #32333- 23-00020 LOT 4 OF SP #3120 AF #2092412 PTN OF G.L. 1 IN SEC 32 & 33, Parcel #32333-22-90140 Township 23 N, Section 33, R3W,NW'A of the NW %, The owner desires to provide a water system to supply water for Parcel# 32333-22-00030& Parcel# 32333-23-00020 The owner hereby dedicates an easement for a well,pump house and facilities which are necessary to produce and distribute water to said properties described as follows: LEGAL DESCRIPTION OF WATER SYSTEM Existing well is located at coordinates 47.44451,-123.07924 on Parcel #32333-22-90140 in Mason County, Washington. OWNERSHIP OF THE WELL AND WATERWORKS The water system is owned by Northwest Logging Company, LLC, hereinafter known as "Owner". COST OF WATER SYSTEM MAINTENANCE The incurred cost of maintaining the water system shall be the responsibility of the Owner. The Owner shall establish a water rate solely at the owner's discretion sufficient to cover system operating expenses,regulatory costs,maintenance costs, establish a reserve fund for equipment repairs, replacement and a return on investment. MAINTENANCE AND REPAIR OF PIPELINES All pipelines in the water system shall be maintained so that there will be no leakage of seepage, or other defects which may cause contamination of the water, or injury, or damage to persons or property. Pipe material used in repairs shall meet approval of the Health Officer. Cost of repairing or maintaining common distribution pipelines shall be born by Owner. Each party in this agreement shall be responsible for the maintenance, repair and replacement of pipe supplying water from the common water distribution piping, commencing at the individual service meter, to their own particular dwelling and property. Water pipelines shall not be installed within 10 feet of a septic tank or within 10 feet of a sewage disposal drain field lines. NOTICE TO FUTURE PROPERTY OWNERS This system is designed to provide for two service connections. Planning and design approvals must be obtained from the department prior to expanding beyond this number of services. Additionally, a water right, obtained from the Department of Ecology, is required if the water system exceeds exemption standards. RESTRICTIONS ON FURNISHING WATER TO ADDITIONAL PARTIES It is further agreed by the parties hereto that they shall not furnish water from the well and water system herein above described to any other persons, properties or dwelling without prior written approval from the Mason County Department of Health. HEIRS, SUCCESSORS AND ASSIGNS These covenants and agreements shall run with the land and shall be binding on all parties having or acquiring any right, title, or interest in this land described herein or any part hereof, and it shall pass to and be for the benefit of each owner thereof. ENFORCEMENT OF AGREEMENT ON NON-CONFORMING PARTIES AND PROPERTIES The owner reserves the right to make reasonable regulations for the operation of the system, such as the termination of service if bills are not paid within forty-five days of the due date, additional charges for disconnection, reconnection, etc. Parties not conforming with the provisions of this agreement shall be subject to interest charges of 18%per annum together with all collection fees. (Property Owner) State of W 'ngton, 4 County of I,the undersigned, a Notary Public in and for the named above County and State,do hereby certify that o this 1 day of , 202 , personally appeared before me fi e(. � PJWL._ to m nown to be the individual described on and who executed the within inst ent, and acknowledge that he (she) (they) signed and sealed the same as free and voluntary act and deed, for the users and purposes herein mentioned. GIVEN under my hand and official seal the day and year last above written. Notary ublic ir_kand for the State of Washington, T residing at O(0 rYW Wi c My commission expires: of I Li / �� 1 AUTUMN JOHNSON I ' Notary Public State of Washington I Commission#23001078 I My Comm. Expires Jan 21, 2027 I WATER WELL REPORT DEPARTMENT OF Notice of Intent No. WE52891 ECOLOGY Unique Ecology Well ID Tag No. BPQ 165 Type of Work: State.of Washington — • l Construction Site Well Name(if more than one well): ❑ Decommission b Original installation NOt No. Water Right Permit/Certificate No. Proposed Use: 0 Domestic 0 Industrial 0 Municipal Property Owner Name NW Logging 0 Dewatcring 0 Irrigation 0 Test Well 0 Other Well Street Address 26141 NE N Shore Rd Construction Type: Method: ©New well 0 Alteration 0 Driven 0 Jetted ❑O Cable Tool City Tahuva County Mason ❑Deepening 0 Other 0 Dug 0 Air- 0 Mud-Rotary Tax Parcel No. 3202290140 Dimensions: Diameter of boring 6 in.,to 80 ft. Was a variance approved for this well? ❑Yes O No Depth of completed well 65 ft. Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread O I 0 6 in. +1 45 1/4 in. O I 0 ❑' I 0 Location(see instructions on page 2): n WWM or 0 EWM ® I 0 6 -in. 68 70 V4 in. ❑ I 0 O I 0 NW r/,-V.of the NW V..;Section 33 Township 23N Range 3W ❑ 1 0 in. _ _ _in. ❑ I ❑ ❑ I ❑ ❑ I ❑ in. _ _ in. ❑ 1 ❑ ❑ 1 ❑ . Latitude(Example:47.12345)47.44451 Longitude(Example:-120.12345) -123.07920 — Perforations: ❑Yes ❑O No Type of perforator used No.of perforations Size of perforations in.by in. Driller's Log/Construction or Decommission Procedure Perforated from ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure,^nd the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: ©Yes 0 No K-Packer b Depth 42 ft. information. Use additional sheets if necessary. Manufacturer's Name Johnson Type stainless Model No. Material Froth• To Diameter 5 in. Slot size 14 in.from 45 ft.to 65 ft. Reddish brown conglomerate 0 38 Diameter in. Slot size in.from ft.to ft. Light brown sand&gravel saturated 38 65 Clay bound sand&gravel 65 80 Sand/Filter pack:0 Yes 0 No Size of pack material in. Materials placed front ft.to ft. Surface Seal: ❑Yes 0 No To what depth? 18 ft. Cut drive shoe at 68'pull casing back to 45' Material used in seal bentonite Did any strata contain unusable water? 0 Yes 0 No — Type of water? Depth of strata Method of scaling strata off Pump: Manufacturer's Name Type: — —. H.P. Pump intake depth: ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing ft.above ground surface Static water level 28.5 ft.below top of well casing Date — Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: i. Was a pumping test performed? 0 No 0 Yes b by whom? — Yield gpm with_ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Recovery data(time=zero when pump is turned off—water level measured from well top to water level) Timc Water Level Time 'Water Level Time Water Level Date of pumping test — Bailer test 1 gpm with38_6 ft.drawdown after.'_hrs. Air test gpm with stem set at ft.for hrs. Date Artesian flow gpm Temperature of water °F Was a chemical analysis made? 0 Yes 0 No Start Date 6/7/23 Completed Date 7/1/2:.— WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance wish ail Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. Driller 0 Trainee 0 PE—Print Name Emily Davis Drilling Company Davis Drilling Signature CO' Address 340 NE Davis Farm Rd License No.3142 City,State,Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DAVISDI1100A _ Date July 2023 Davis Drilling 340 NE Davis Farm Rd Belfair, WA 98528 Test Pump for: Northwest Logging Address: 26141 NE N Shore Rd Well depth: 65' Well Tag: BPQ 165 Static: 26.5' TIME WATER LEVEL GPM O m 26.5' 0 15 m 46' 5 30 m 65' 5 2 h 65' 1 4 h 65' 1 RECOVERY 1 m 64.3' 2m 63.5' 3m 62.4' 4m 61.4' 5m 61.8' 15m 58.8' 24 hr 26.5' I