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HomeMy WebLinkAboutWAI2024-00008 - WAI Health Waiver - 1/22/2024 (2) ..- 0..3 161/4 t, e/ACYIA-15 0 CL)B . , sti J0 rr t� a w `' MASON COUNTY COMMUNITY SERVICES V T ":�� ;�v Building,Planning,Environmental Health,Community Health tO) t i.�.t�':�\` 415 N 6'h 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 LE �� Amount Paid: I4. " BAN 2 2024 Receipt Number: Q4. - d 0 3 Instructions By-- 1r, 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. Cep- "W �I+�.� PART 1. Applicant/Parcel Identification �" G�J�, �( Name of Applicant [cry( ans�� Telephone(5 lYC)-1 10 `7 a -J ,, Mailing Address of Applicant ilC+ll) Lida th.rbep CitySne L Itiri State tt Zi gYf.t-i l� 12-digit Tax Parcel No. 3_ 3O -- -- o o I i Site Address / Li/0 t / 4_,)i led Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) ❑ Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies 0 Group B Water System Regulations ❑ Location,WAC 246-272A-0210 X Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations ❑ Other Description of Waiver/Appe-I (include jus fication, additional mate ial may be att- hed.): / � - .. IL_ ►.,. ...._4 . e 1 . • must_ y. wiligmtixtrampamsfra _ I; c A grin MIrarIM_ ,. �..1 ilk /' Date: 2 q Applicant Signature: ,. .i�11/1 �4 I- 0� - J:\EH Forms\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 XWaiver 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. Nature of Appeal:, imin gvailVty of wgldr alrai'l4blo from Soo al per' Camilla/on er'da (l6AP il tota(7 to 'Isogal Pee coliflec a i l dq (?oO,/d 1v1 1). P Y �� r 4. Hearing Official: ❑ Board of Health 0 Health Officer O Pollution Control hearing Board ,lam Public Health Director O Certified Contractor Review Board 0 Environmental Health Manager 5. Mitigating Factors: y 4 e r- ' s."l . ► a G.* 1 fi J / e' ( /(low ,I ii —oau►u .ice gr 0 ' . 1 . .1/ . .. niFr J ► c valor' ryh5-. 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. L Staff Signature: k..---- Date: 1` /fG Zv7 / 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: ❑ 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: �: Date: Ll 2 4 J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 2of2 WATER WELL REPORT ...NM DEPARTMENT OF Notice of Intent No. WE48258 Type of Work: IN ECOLOGY State of Washington Unique Ecology Well ID Tag No.BMT 156 U Construction Site Well Name(if more than one well): 0 Decommission e0 Original installation NO1 No. Water Right Permit/Certificate No. Proposed Um I'9 Domestic 0 industrial 0 Municipal Pro O Licrt Dcwatering 0 Irrigation 0 Test Well [1 Other Property Name Mike ijld Evil Babe( Construction Type: Well Street Address 1430 Clocivaflum Road Method: — ®New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County MaSO11 0 Deepening ❑Other 0 Dug 19 Air- 0 Mud-Rotary Tax Parcel No. 320303290012 Dhneailots: Diameter of boring 6 in.,to 219' R. Depth of convicted well 218'6 R. ' Was a variance approved for this well? 0 Yes 0 No Construction Details: Nall If yes,what was the variance for? Casing Utter Diameter From To Thickness Steel PVC Welded Thread U I U 6' in. +2 213' 1/4 in. .(2) I U (Ell U Location(sec instructions on page 2): 0 WW or 1] W EM U I 0 in. in. U 1 ❑ 0 I U M O 1 0 in. in. ❑ 10 ❑ I ❑ NW V.-'/of the SW V..:Section 30 Township 20N Range 3W ❑ I 0 in. in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345)47 19366 —— — - Longitude(Example:-120.12345) 123.11561 Perforations: 0 Yea ❑Nu Type of perforator used --- No.ofperforatiom - She of perforations is by in. Driller's Log/Construction or Decommission Procedure Perforated from It.to II.below ground surface Formation:Describe by color,character,sine of material and stra:ture,and the kind and nature of the material in each layer penetrated,with at ka..t ow catty fur each change of Screens: ©Yes fJ Nu l K-Packer ' ' Depth 212' ft. information. Uso additional sheets if necessary. Manufacturer's Name Johnson Material From To Type SS Tele Motel No. Diameter 5 in. Sksl size 12 in.from 212' R.to 218' ft, CLAY,LOAM WI GRAVEL (BRN) 0 3 Diameter In. Slot size in.from n.to R. GRAVEL$CLAY HARD (SRN) 3 44 CLAY,SILT,GRAVEL,SAND (BRN) 44 57 Sand/Filter pack:0 Yes Iii No Size of puck materiel in. GRAVEL,CLAY,SILT,SAND (BRN) 57 73 Materials pL-tecd from_ft.to ft. --- GRAVEL,SAND,CLAY TP (LT.BRN) 73 98 San r.«seal: a Yea 0 No To what depth? 18 n. CLAY,GRAVEL,SAND (GREY) 98 108 Material used is scat Bonlonito Did any strata contain unusable water? 0 Yes 111 No GRAVEL,CLAY,SAND,TP (GREY) 108 111 Type ofwala7 Depth of strata - CLAY,GRAVEL,SAND,TP (GREY) _ 111 119 Method of sealing strata off PEAT _ (DK BRN) 110 122 SILTY CLAY (GREY) 122 133 Pump: Mamtfncsutor'sNnme TYix - SILTY,CLAY,SOME GRAVEL (BRN) 133 148 ILP. Pump intake depth:_it. Designed flow rate. gpm GRAVEL,CLAY,SOME SAND TP (BRN) —148 196 — Wafer Levee: Land-surface elevation above mean sea level ft. GRAVEL AND SAND TP W/B (BRN) 196 219 Stick-up of top of well casing R.above ground surface Static water level 171.-1' ft.below top of well casing Date 6/3/2022 Artesian pressure lbs.per swore inch Date _ ___ Artesian water'arnntrolbedby-- ________ (cap,valve,etc.) __-.-.----._------------_ ------ -----.. Well Tests: Was a pumping test performed) 11 No II Yes r. by whom) --- Yield gpm with ft.drawdown ever her. — Yickl _-_ .pun with_It drawdown after her. ---------- - -- Yield gpm with ft.drawdown after hrs. Recovery data(time o zero when pump a turned off water level measured front well top to water kw!) lime Water Level Time Water Level Time Water Level Date of pumping teal Bailer test gpm with ft.drewdown oiler I n. Air test 15 gpm with stem set at 210 R.for 1 her. - Date 6/3/2022 Artesian flow gpm --- - --- Temperature of water '1' Was a chemical analysis model 0 Yes ❑No Start Date 6-2-22 Completed Date 6-3-22 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of Ibis well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. O Driller❑Trainee❑PE- ' t Na a Dan Corpo ter Drilling Company TIMS Well Drilling _---_- Signature R M f ri er -- Address PO Box 14996 License No. 2238 City,State,Zip Tumwater,WA 98511 (F TRAINEE:Sponsor's License No. _ Contractor's Sponsor's Signature Registration No.TIMSWWD834DN [)ate ECY 050-1-20(Rev l 1/18) if you need this document in an alternate format,please call the Water Resources Program at p}�" g" F 360-407-6872. .• Person with heating loss sou call 711 for Was/tiegktu Relay Service. Persons with a speech disability can call i s '�1.. �, 877-833-6311. t.3.z.-.'c.r: Fenn, R..-sr",-, ('n, -n, .r-INA C;