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HomeMy WebLinkAboutWAI2024-00008 - WAI Health Waiver - 1/22/2024 � WA, t, 10-1A,-6 o 00 5' J •NFL,.� ,4,,, 0 ,-IP,m-„ MASON COUNTY . , _ !� -; 'r COMMUNITY SERVICES y? __ '4C Building,Planning,Environmental Health,Community Health '03.H:I'iV2N-0. 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360) 275-4467 ext 400 s• Elma: (360)482-5269 ext 400 FAX (360)427-7787 Application for Waiver/Appeal 0Amount Paid: I q.S" 1IIL r J4N 12 Z Receipt Number: q.4,-- do 3 024 Instructions 1 Ev__ l 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. C11-- W v� PART 1. Applicant/Parcel Identification Name of Applicant l M(.1 'Ct{'15, ✓1 Telephone c5(YO'l /O '0 D Mailing Address of Applicant J�Q l l I,4 C City)e L l ` State /l/'' Zi q y re 3 0 -- -- V 00 0I 1 12-digit Tax Parcel No. 3 0 f`� //�� C/ c,a Site Address ' ��(� l , / �_` // 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 ❑ Group B Water System Regulations ❑ Location,WAC 246-272A-0210 )74 Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations O Other Description of Waiver/Appe I (include jus ification, additional material may be att hed.): 3 e . ti 1 -�- d 1 `--'i n .Z Applicant Signature: Date: I - OVA - au' ...... ,.., 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 Waiver i 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. N9,tur9 of Appeal: Aaa vi~G NYItMin tva Otr of wiler al'✓ i(gb(B frown goo la( per amrectionl per day (Po pri �a 17 to 'I So a( Per con fec'i fee orgy ( N ). Y 9 9 Y 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board XL Public Health Director O Certified Contractor Review Board 0 Environmental Health Manager 5. Mitigating Factors: ; : 8 .' # ' -t . . ,, la.. 1 ,,,,, .' , e• ( / y ( 14117i/ %S . I !/ 0 ' 1 1 . .// .1. . AAI / C wa¢eir ri h fi. 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: /1f/ZOVY 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: �"" Date: L( 2 ' 4 Hearing Official Signature: J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 2 of 2 • • WATER WELL REPORT r.,e O DEPARTMENT OF Notice of Intent No. WE48258 ECOLOGY Usti ueEcolo Well ID TagNo.BMT 156 Type of Work: State of Washington 9 gy 1' Constructiva Site Well Name(if more than one well): 0 Decommission r—y Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: Igi Domestic 0 Industrial 0 Municipal Property Owner Name Mike and Eva Bober 0 Dcwatcting ❑Irrigation ❑Test Well O Other Contraction Type: Method: Well Street Address 1430 Cloouallum Road 1 New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other 0 Dug IN Air. 0 Mud-Rotary Tax Parcel No, 320303290012 Dimensions: Diameter of boring 6 in.,10 219' n. Depth of completed well 218'-6' n. Was a variance approved for this well? 0 Yes 0 No Cowtruclloo Details; Wall If yes,what was the valiance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread El I 0 6' in. *2 213' 1/4 in. Let U Ie1 Li I � Location(sec instructions on page 2): 0 WWM or El EWM 0 I ❑ in• — — in• ❑ I ❑ DID❑ 1 CI in. _ in. El I 0 ❑ I ❑ NW VI-V.of the SW W.Section 30 Township 20N Range 3W ❑ 1 ❑ in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345)47 19366 Longitude(Example:-120,I2345) 123.11567 Perforations: 0 Yea 0 No Type of perimeter used No.of perforation Size of perforations in.by to Drller'a Log/Construction or Decommission Procedure Perforated from IL to n.below ground surface Formation:Describe by color,character.size of material and structure,and the kind end nature of the material in each layer penetrated,with al kart are entry for each change of Screens: ©Yes 0 No ❑a K-Packer '' Depth 212' n, information. Usoadditionnl sheets if necessary, MeafaUuv's Name Johnson Material From To Type SS Tele Model No. Diameter 5 in. Slot size 12 in.from 212' ft.to 218' R. CLAY,LOAM WI GRAVEL (BRN) 0 3 Diameter In. Slot size M.from n.to n. GRAVEL&CLAY HARD (BRN) 3 44 CLAY,SILT,GRAVEL,SAND (BRN) 44 57 Sand/Filter peck:❑Yes fit No Size of pack material_in. GRAVEL,CLAY,SILT,SAND (BRN) 57 73 Materials placed from R to n. GRAVEL,SAND,CLAY TP (LT.BRN) 73 98 Surface Seal: a Yea 0 No To what depth? 18 n. CLAY,GRAVEL,SAND (GREY) 98 108 Material used in neat Benlonito GRAVEL,CLAY,SAND.TP (GREY) 108 111 Did any sone contain unusable water? 0 Yes E No Type ofwitefl Depth of strata CLAY,GRAVEL,SAND,TP (GREY) 111 119 Method of scaling strata off PEAT (DK BRN) 110 122 SILTY CLAY (GREY) 122 133 Pump: Manufacturer's Name Type: SILTY,CLAY,SOME GRAVEL (BRN) 133 148 ILP. Pomp intake depth: ft. Designed tow ate:_gpnt GRAVEL,CLAY,SOME SAND TP (BRN) 148 196 Water Levels: Land-surface elevation above mean sea level R GRAVEL AND SAND TP WB (BRN) 196 219 Stick-up of top of well casing IL above ground surface Static water level 171'-1' n.below top of well casing Date 6/312022 Ancslan pressure lbs.per square inch Dale Artesian swcr is controlled by ___--(cap,valve,eta) ._.— -_—___--_-..— ----"- Well Pests: Was a pumping tat performed'\ 0 No i.)Yes rr by whom'? --- Yield gem with fl.drawdown after_hrs. Yield grim with_n.drawdown after hrs. Yield grim with_n.drawdown after hrs. Rr.cu cry data(time=zero when pump is turned off-water level measured front well top to water keel) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer teat gpm with n.dawdown after Ins. Air test 15 gpm with stem set at 210 ft.for 1 has, Date 6/3/2022 Artesian flow gam Temperature of water •F Was a chemical analysis made? 0 Yes 0 No Start Dato 6-2-22 Completed Date 6-3-22 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above arc true to my best knowledge and belief. 0+ Driller 0 Trainee 0 PEnt Na a Dan Ca a ter Drilling Company TIMS Well Drilling Signature _ Address PO Box 14996 License No.2236 City,State,Zip Tumwater,WA 98511 IF TRAINEE:Sponsor's Liccnsc No. Contractor's Sponsor's Signature Registration No.TIMSWWD834DN Date ECY 050-1-20(Rev 11/18) !fyoveed ibis document 1n nil,alierytate format,please call the Water Resources Program at -. ---36fN07,-687L PmtFmtrir1lh(hegi rrg(1 r;cont o i!l7!1 fqr WaJilrrgroil Relay Service. Persons will'a speech disability can call 8 7 7-833-63 41,