HomeMy WebLinkAboutWAI2024-00106 - WAI Health Waiver - 12/3/2024 MASON COUNTY
COMMUNITY SERVICES
Builtine Planniip,Emlronme�l Nmlth Community Hmltlt
415 N 6"Street,Bldg 8, Shelon WA 98584,
Shelton:(360)427-9670 ext 400 O Belfair. (360)275-W7 erd 400 a Elm:(360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid:
Receipt Number:
Inatructlons \ �Nu`T
1. Complep Pap 1 and 2.No determination can be made urdil these parts are fully,,,hoisted.
2. Faea may be—ror waMre and appeal,oaem on the Environmentel Health Fea Schedule.
S. Submit completed application with attachments to Mason County Public Health for rewew,
PART 1.Applicant/Parcel Identification
Name of Applicant BRAD ANDERSON Telephone
Mailing Address of Applicant 2420 NE BOULDERSTONE CT
City POULSBO Stale WA Zip 98370
12-digit Tax Parcel No. 2 2 1 0 5_-_ 5 1 _ _0_0_0 5 7
Site Address XXXX MASON LAKE DRIVE EAST-GRAPEVIEW
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Contractor Cert81cation Requirements
❑ Class B Reduction in Vertical (Installer,Pumper, 08M Specialists)
❑ Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
1 Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Crane Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification,additional material may be attached):
REDUCE SETBACK FROM DRAINFIELD TO(2)WELLS FROM 100FT DOWN TO 75FT
EVIDENCE OF SURFACE SEAL,CONFINING LAYERS THRU WELL LOGS(SEE ATTACHED)
ENHANCED TREATMENT PRIOR TO DISPOSAL,ANNUAL Q/N REOUIREO
Applicant Signatu a ate: 1 2-(3 U Ly
1:M FsnnA WsiwnAPWW Meson Cowry lour Revisal 1202017
Peas 1 a12
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal raiver ❑ None required c Class A ❑ Class B ❑ Class C
2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) f pfG6 L 7Zf} OZl O
3. Nature of Appeal 1J � ` n• m �A _r L 1 _
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board )K Environmental Health Manager 5. Mitigating Fact
orsi A
W f " TV
- �ti( N NovS fti �i 01:I
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted. r,-,
Staff Signature: ItAI "-^"'M7 Date: t 713 / K_
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: t Date: 11" T 2
I:IEH Forms\Waivrr-Appeal Meson County Loral Revised 1/20/2017
Psge 2 of 2
ppIe•�k RECEIVED
WATER WELL.REPORT DEPARTMENT OF NotiUOflntenl No. W M215
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❑ Ori®W iowYeoa MI No. Watm Right Pe:mibiCOMMite No. WA State Depa, Ilt
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hiNod orwlgewd Gruryush blwm 11111Y ryle tumults 125 les
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WELL CONSTRUCTION CERTIFICATION: 1 wrvinwlM eIINa a�cM responsibility,far aannmctim ofins well,and it,1 camlifmcc weh dl Weshil lon uell
oon4roclion skrdads.Mekruo aeon mM the mfammion epwM shove em aoe to in,Est kmwRMgo eM belief
❑Driller N Traime❑PE-Pont Name CitRY JONnaon Drill g Comm Compony N da Drilling Inc
S rm Addam PO Box 1790
[imlmN 3 1T I C'W Sw Zip Shelton WA MEPI
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Fe:MNbaI.w FMd olker Loer was WATER WELL REPORT """"°.` 0 376
wrnn.a el E<aeo �1 11
mon d — Case, STATE OF WASHINGTON
maar I l(eSA"yl��s
Calls Weer aNnl IxMW.
(1) OWNER nmns Jim Andreasen aeons. F. 1I00 inscIa Lake Drive W obel:l n.Na
C
Q. (E) LOCATION OF WELL: Deaxr .Ims on .�'Yr a 1'% all r 21 x.,R 2 w.x.
(211 STREET ADDONESS OF WELL to,.arw aNws)
j (3) PROPOSED USE: ❑ Iowa it Ilqugrial ❑ uundgl❑ (10) WELL LOO a ASANDOMENT PROCEDURE DESCRIPTION
IrHmt❑ DeWeter Twt WN ❑ Gains, ❑ FaMews: D.be x a as Sa . andrand., sea a Mxlas and xpeen.asp won
y mal.ra a atww.aN p.IM m.Wnm tp w deve,in saps arYM w.enpe.
as_+ (4) TYPE OF WORK:f pan aMeiesrawll gdswbrxr ra.amwrmbrwwntlw.
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C Aleandxpd❑ Nell IX Metnad: Due ❑ Dbaed ❑
C De.Pxlad ❑ cm. L3 pban ❑
C RMonGloneed❑ "MY❑ JaaM ❑
0 (5) DRAENSIONS: Dlan.termwml 6 belle.
iD Dnnee_1Z�a.l. apaaedmgx.e wml 179 n.
E (S) CONSTRUCTION DETAILS: Silt• sand a revel same h20 2
Cagng mepnW: 6_• Dm.n plU9 1 sass 177
C welded 3 Dlun.ewn •p a. •r
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47
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g vwana«win N wan bJs Dina —
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(0) WELL TESTS: leaned Nl.nvp.11e e..rlwlo.xxppsr
..r W...awP basn"0Y. M aww.pgsewf WELL CONSTRUCTOR CERTIFICATION:
C Ybp:_—gLLtmb..M nda.dwr an.r_—Ill. I conmructee and la accept raeponOMlNy ear constmelion of Isle well.
and I. axewwa. won .n Washington all ao.MMtlw elelaare..
Malenae used and the blxx.tbn,waned above Me Iran le my beet
gapaxy yultlxawnw a.axewlMPwlxwdxDbeprlwglNMMw Nnowledgeendbeliel.
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An.rwlpw aF... Dine
TrnF.m..a.rx_w..wxrcal a.wrs..aq He—
Elv. ND0 (USE ADDITIONAL SHEETS IF NECESSARY)
oldo d .,an _1..F 4Wa
4�3439�'
WATER WELL REPORT CURRENT
0,1E-1w I"copy-Leolo,,,Pmpy-a ,J"-py-drioer Notice of lohnt No.WE 09682
y ECOLOGY Construction/Decomminion("T"in circle) Unique Ecology Well l D Tag No.BBE 049
Ronslructlon Water Right Permit No.
m ❑ Decommission ORIGINAL INSTALLATION Property Owner Name cm„e LeVAS
t Noticed /"tent Number
PROPOSED USE: ® Da—"k ❑ Idr-rk1 ❑ Mmklpl Well Street Address aag0 E Mew tale Di W t
C ❑ Dewwr o Iniwion ❑ Te%wa O Qk,
O City Cnatce,a w County Masan
TTPEOFWORN: Owner',numberofwell(ifr-,etu o-)_
C Location MI/4-1/4 ,MIA Sec§ T. 1�N R2W twM a
O ® New wrll ❑ Recmailbmd Mdhm:Cl ME ❑ Boni O 11uwn
'err 13 Detmna ® cable 0 Ream, Q 1-d is,y T Still REQUIRED) a
m mMEMIONS: Dvrmrcrofwsl151nrbea,ddlkd7C fl. _ W
E O haft Ines tnell 16311,
CONSTRUCTION DETAILS tat/Long Lat Deg _ tat Min/Sec _
w
C Citing ® welded 5' Dkm.fmm S n.to 155 ft. Long Deg_ Long Min/See
I.IW: ❑ LIM,1-e11al - D.D.fmm_Rk fl. Tax Parcel No.(Required)221266100062
QI ❑ notmi d Not.From It. _a.
Pe,lonHa-: Yes No C'ONSTRUC 'ONOR DECOMMISSION PRMEDURE
V Typeofperfa-auud Forn4ian:DexriSe by eobr cNnun,ai-ofmrerul aM M th Amum,ae Mud!utl
SIZEof,rft .le,_in..M...f,ofi_fiom_R.to_0. -rne ofrhe,-mist inach HraaonpeMraled winet leap.too,fi,wehahat
_. . . ._ ofinMmwrion. (USE ADDITIONAL SHMIni IF NECESSARY] -
Cseeetir-9 Yer -ElW ❑-K-Px -Wn7on 146
R MmuScrum's Nam,Johnston Dark brown lopsoll MATERIAL FROM 'O
Type Slotted Stainless Model W, Brown wnglomMate 1 11
0 Di—5Slm,i..M Rom 10 A to JRR Gray Hardpan 11 22
G Dmm,5S1ots,x. 10fietenj5BILI-16311, SlRbound sand and gm" —22 31
d GnwRMNnmehd: ❑ Yet ® w Soeofprveu-M_ Redish tram silty 31
L Mnarua puree Ram_it to R. "no aW 9raval 44
Sodom smu: ® Yes O No To whe dwh?21R Brown hardpan M 62
C Mweied toedinreal Bontonbn Chins Grown silty sanE and 9faval fit 64
1Q DidmY Hnu amain unwbk water? ❑ vas ® No Light brain hardpan ne 101
TYmafwakr? DnNhafprm Brown wn9lonerate 101 159
3 Maumdofrcali,Muton MedlOm sand with trace 150
at 9ranN,water beating 163
NMP: MenuDmmer'a Name
0 'pipe; H.P.
Z WATERLEVE49: IaMsvf ekr4im abort meanwkwl_R
U) Star ktel4Tn.belntmofw11 one 11/17/2011
8 Anee6nprcewm_Iba.,1,.mineh Not
10 A-,knwwrnkcommlledby. IW,"tth`ecu.)
�a WELLTP.4I3: Rewdown it amounwarer kvelbbwertd hbw eut'r kwl
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Q Yitw: wilR_fl.bawdown afler_M1n.
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{{I YkN:_®IlMn wpk_fl.hewdwnaMr_hn.
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V ,— worvlewq
y Time Warn Lev<I Time Werer4vel Time warcrtewl t
T
d
Dwaflnt
anrkrrcn 20 pllmin.with lea BawWwneMr�ka.
Airn61_ml/min.wiN akinsl al_fl.fw�M.
fY Arleaun Raw�Fm Due Smrt Date 1 2 2011 Co lmd Date 11 17 11
FTeot,ent—afwtler_Waeatlemicelerelysu nWe4 0 Yo ® No
WELL CONSTRUCTION CERTIFICATION: I constructd and/or accept responsibility for wnnmchun ofthis wc11,ad its eomplhee,with all Washington well
cwnmeum R,ndit Matenshuedad the information neported above are twe tomYbeSt lu,"Jedgeandbelid
NDfiftentut.interf ITen. Name(Pdm)Mark NCI,M/ ./ e, Drilling Co Atedia Drilling Inc
WiledEngiamoTefinateSepatine Po Boa I'/90
DdIho.r tmnee Licen-Na.1992 Cr7.Sum,Zrp SM1elwn Wa, 96384
IF TRAINEE:Driller',Limns Net: Cmtnetw's
Dille.Si®tetue. ftietrebtnt No ALCAD2192ILLDEe 11222U11
WY050-1-20(ft,02/10) fJrouneedfbl,dwmrMatlnanalmmale%rmxa6Mememlltde Waio Rewu¢ PmBrama13R0- O71 72.
Perswu with kmtlng lw,wn mlNll/or Wpshirglon Relnv Servlre. PerweuxirAasp hdvbiliNcanwit817833fi341.
Pioneer Digging Inc.
3083 E.Mason Benson Rd.
Grapeview, WA 98546
DANIELS,MICHAEL J 11/9/2024
12234 SE 57TH#263
BELLEVUE WA 98006
To whom it may concern:
I am a Septic Designer working with your neighbors on Mason Lake,Brad Anderson,on a
new septic design. This letter is to inform you that the Andersons have made application for a
waiver to locate their septic drainfield closer than the standard setback of 100 ft. from the well
located on your parcel,but not closer than 75ft. Washington State allows these setback reductions
provided it meets specific mitigation measures which include enhanced treatment prior to disposal,
and evidence of confining layers, surface seals, and/or excessive well depth. I have attached the
site plan from the design for your information.
We are required to notify you of this application as part of the review process. If you have
any questions or concerns you may contact myself or Mason County Health Department at the
numbers below. Thank you for your time.
Pioneer Digging Inc. -360426-1803 -(Robert H. Paysse/Designer)
Mason County Health Department- 360-427-9670 -Ext. 400
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U,S Postal Service
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Bell evuet WA 98006 ^-T
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13 $0.73 11/12/2024
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v' c'-"srie�" arvC lsO R.. °I$ oo L
Certified Mail@ $4.85
Tracking N:
9589 0710 5270 0293 6865 44
Return Receipt $4.10
Tracking N:
9590 9402 6074 0125 8408 76
Total $9.68
-------------------------- --------_-_--..-
+ Grand Total: $9.68
--------- --------..--.-.-.--- ----...._-_---
Cash $20.00
Change -$10.32
Text vow tracking number to 28777 (2USPS)
to get the latest status. Standard Message
and Data rates may apply. You nay also
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UFN: 547742-0388
Receipt 8: 840-59800265-4-6970035-2
Clerk: 05
0- PROPOSED DRAINFIELD
PRIMARY & RESERVE
QOP ` FVIVRE
DRIVEWAY
lob
EXISTING WELL �l
PROPOSED __i �) \ 0' ^I II
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MBR0.5-N / �; ♦\ 11 FARE \\ �� R75' �I
/ GARAGE
/ADU
� EXISTING WELL
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c�}:m'w.xeas �0\
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ANASBUILTIINSTTALLSIGNGFF FEE PALL TEST HJI.EF TEST HOLE 2:
BE CHARGED AT TIME O PAF INSTALLATION TEST
Bl Y ATIDFR�N p2+GLS 036 US
FwT 24 GONN('S 36F LOA��
.oNEFI7 ill('.C;Il\IC>4 ING PARCEL t 2210531WG5.1 W ioois 2+ Ruars"
C1Vl�la..+. ADDRESS: pG0(AIA�NIICDR
SEPTIC DESIGNS IGN TRPAISSETd ""0 a.„w•° � q0
EW,WA985W DESER: E
GRAPN
3083 I_KAON BVN DNRD. n. r3 SHEEI` S1IE fl.AN
OFFICE-36042&M03 FAX 360'4 __