HomeMy WebLinkAboutWAI2023-00102 - WAI Health Waiver - 10/16/2023 AMMEMEMMINIMINft
U-3 4 % 23 - t o t o L
MASON COUNTY
•' l' �o COMMUNITY SERVICES�_ }
T• f�
�,,,. ,`c Building,Planning,Environmental Health,Community Health
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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 tE II,, �l�
Application for Waiver/Appeal
Amount Paid: ‘100 f� u OCT 16 2023
J Receipt Number:
Instructions BY-_ e--
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 fJc I o Me. P(M i.! Telephone 3G0'' i-/ 7 G- te22/
cid B-Lrx. CwIA
Mailing Address of Applicant .2 Q7 f e ' i�h.j�fP f L �,L„ a.)
City fAse A/ State (�q, Zip 7psty
12-digit Tax Parcel No. 02 1 ? 2._ -- Li{ / -- 7 Cr .7 3
2. �U t�
(
Site Address 9 L� Co vt 12e I ' _PA,.,01,,/
Subdivision Name and Lot -rt. se s' GL.. 3 7 ...j e` 5'P - -7s
f b
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
Att Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ 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.):
�1td�/I cc 11 aft )d I de/amt.,. /it , L.,/ .i,/<
->° CdtAfiJ6,erz
•of)j ...0'
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Applicant Signature: V Date: / V 0 2
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 1 of 2
1
PART 3: . Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Appeal XWaiver ! None required DGlass A Class B Class C
2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/
Standard revision) t j i9.4 �1' -2 ,7 — d Z /G Tad k
3. Nature of Appeal:
1 d s /we SOP+ Lii
4. Hearing Official:
❑ Board of Health 0 Health Officer
O Pollution Control hearing Board 0 Public Health Director
O Certified Contractor Review Board �'' Environmental Health Manager
5. Mitigating Factors:
400 -GI LA,AIets' LA./c4l
t /____4tAsi diet.Lf 4 c (No 14 a�idr1 !✓_t„(/
yr a. l TL 2
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitter'
Staff Signature: `" ' Date: /Z/.r 2J
PART 4: Determination of the Hearing Official
C 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 adversely effect public
health and is hereby denied. This decision is based on the following findings and conditions:
Hearing Official Signature: 111/1P-7 Date: / 2"-f/2/
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
,e Original and Fist Copy with 5e-121J 91•
partment of Ecology WATER WELL REPORT P cabin No. .
cond Copy-Owner's Copy
.ird Copy-Driller's Copy STATE OF WASWNGTON Permit No. ....
i..; 1 OWNER: Name......- .... 00. .1:......._.__..... Address 3J..7O // dnf.... iliAii-•. ...O.' LOCATION OF WELL: cuunty..4J1 fdN — / feAfcms.../..t...
e ,/V ;s SecYse2 T., ../ N., It 1-4.M.
Y •.r,nit and distance from section or subdivision corner- - - --_ __ __ -_
;) PROPOSED USE: Domestic y Industrial ❑ Municipal ❑ (10) WELL LOG:t1J - — —_
Irrigation ❑ Test Well Q Other ❑ 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.
in 1) TYPE OF WORK: Owner's number of well -- - -
• tit mole than one).... MATERIAL i FROM TO
New well Method: Dug {] Bored 0 y++.il^ 0 i
Deepened (((❑ Cable Driven Q �"'d�iJ - -— +-
O Reconditioned ❑ Jilted Q H#9 ptN I . y
_ /� Fhe S ed AVE) £',9 GeAVEs a i J b
O i) DIML'�NSIQQNS: Diameter of well ..._......�z.]_. ltnches. t*_ s•ANoaJQ 4 99(,7 �Qp�c -I „f'
Imi Drilled ... 1 a..1___.....ft. Depth of completed well I...�l it f• ! $i a /� IA�Z� -.. _Ate,- jf-
R G .�.y vIt 4 h0 ___Y7__
CONSTRUCTION DETAILS: ! S� 0 �Y NO AND SOhes. _2 7 79
o Casing Installed: ... slam. from .. ........... n.to ./.. ft. ke C14 r AA/A .4RA✓lf. .
Threaded Q " Dtam. from ........ ft.to ft.
c ��/�IIO ._ , 4 I ! !at-
Welded 0 Diam, from _. ......... it. to _......_..._. ft. L� 11 /Rl 1
1
E Perforations: yes c No col FP le `�464V " .j46'D 1 9 13
O Type of perforator used i GRte. Ctlq f i� .'y -
_ SIZE of perforations 'in, by ..........--•-•---..._...._ in. IO / y / �y
perforations from _......___..._..... et.to _. .... ...... 1ti. NC . i 9r - /l / AP/
perforations from .........--•--...._. ft.to._ _..__._. n f / 1
.... perforations from ft. to ..._ ft. 1 iii L �� 14.3
R — - 1ii'L G/4 Y B a S• tJD . /L I 7
ca Screens: yes❑ xo - '
SanoA�0 G124✓ A• 177 /d1--
Manufacturer>Na
= Type
Model No
fa Diam. Slot size from ft. to .._...... .... ft. .- .
Diam. Slot size from • ft. to .._ _ ft. --an-r".--
1; kCi
_—
= Gravel packed: Yes CINo le Size of gravel: _ 'N _
Gravel placed from tt.to ft. -- -. T -a ••.
ca
Surface seal: Yes No❑ To when depth? l...Y--•-•--- ft. - --- • L— 1
Material used 1 seal..-..A041:ttbi.re _._ ..._... - - --_.--,-
D Did any strata contain unusable water? Yes 0 No p - __r ---
z Type of water? Depth of strata . __
)
-
Method of sealing strata of.. . �_/
(� , ) PUMP: Manufacture 's Name..T F /IVr v W, ,.,•!/. -- - ----- ----•— -- — --
O
Type: * 3
a �/li 4 II _.... /�,f
.
Land-surface elevation -- - --- -- -� ---
ZT ti) WATER LEVELS: above mean sea level.... _..it.
O anc level ..........1.w..9 ft. below top of well Date...CVO, --
. • ___
O :tesian pressure . lbs. per square inch Date _ -- __ -
✓ Artesian water is controlled by
IJ (Cap, valve. etc.) - --------------- .
Drawdown 1s amount water level is - -
O 9) WELL TESTS: lowered below static level 19_. Completed ¢�
� Wort started����-..-._. � �f� I9 a i.-
C •as a pump test made? Yes(l No X If yes,by whom?................................
a) field: gal./min. with ft. drawdown after hrs. WELL DRILLER'S STATEMENT:
E _ "_ This well was drilled under my jurisdiction and this report is
s- .. .• '• true to the best of my knowledge and belief.
0. ,ecovery data (tune taken as zero when pump turned off) (water level S /, 1 !�
measured from well top to water level) NAME ✓ 1s oa kM (Jell O!( 'i ,/
Time Water Level I Time Water Level I Time Water Levet (Person, firm, or corporation) n(Type-Er print)
_ Addr a j O 4*` 4 iR......go
r
Date of test [Signed]. r.
nailer test....J.v.......gal✓min. with......... it. drawdown after.-_ bra. (Well Driller)
Artesian flow .Y.pm. Date..............._.._._........ - _.... / /y aQ
IV
gel
Temperature of water. ......... Was a chemical analysis made? Yes❑ No Q License No..../ ` ". Date... / T 19
(USE ADDITIONAL swum IF NECESSARY)
4111110 a
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