HomeMy WebLinkAboutwai2025-00018 - WAI Health Waiver - 3/21/2025 MASON COUNTY
COMMUNITY SERVICES
Building Planning Em' menml Health,Community Health
415 N 61°Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 6 Belfair: (360)2754467 ext 400 J Elms: (360)482-5269 ext 400
FAX (360)427-7787 (� �//(�
Application for Waiver/Appeal n�l(7�O \r/ E D
Amount Paid: 20O Illnlf MAR 2 5 2025
Receipt Number 2025'Q/1P55
Instructions WA 12 025- OOC� I� By
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 CODY B STEPHANIE POWELL Telephone
Mailing Address of Applicant 16014 BAY RIDGE DR
City POULSBO State WA Zip 98370
12-digit Tax Parcel No. z 2 3 3_0 ___ 5 0 __-_0 _0 0 B 2
Site Address 41 NE RHODODENDRON BLW
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
Cl Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
rl Location, WAC 246-272A-0210 ❑ Water-Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification, additional material may be attached.):
REDUCE SETBACK D/F TO MULTIPLE WELLS(7S+).
DRAINFIELD WALL BE PRE-TREATED W/NUWATER BNR 500 MEETING TL-B W/OUT DISINFECTION.WELL LOGS
ATTACHED.NEIGHBORING WELL OWNER NOTIFIED(COPY OF CERTIFIED LETTER ATTACHED).
Applicant Signature: 4 U Date: ? 2f 2-
1:\EH Fonos\Waiver-Appeal Mason Comty Local lk viwd 1/20M17
Page 1 of2
i
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 o Class B ❑ Class C C✓� �,
2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) 'I //
3. Nature of Appeal: LVL)) t-0 Drgt✓4-,g Tn 76"
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board ❑ Environmental Health Manager
5. Mitigating Factors:
5/ d4, s'o e
(M yr
Lt CNf/O
S. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Staff Signature: Date: T r L)
PART 4: Determ' ation 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 denled. This decision is based on the following findings and conditions:
Hearing Official Signature: Date: / V
1:\EH Fonns\Waiver-Appeal Mason County Local Revised 1/2012017
Page 2 of2
RECEIVED
FEB 18 2029
WATER WELL REPORT : =01PARTMLNT of N:AloeorMlml Np. M57947
ECOLOGY Unigm Ecology WeHMTagNo. R =O PartmonY
In,mf Wedn stare of Wmh1m mn
am"
Site Well Name(ifmm than an.11): y
toWRO
❑ Reamminivn O Oripnel maimam NOI No. Wtiv Right Pefmil/CenifnYe No.
Pvprd U.v MFamiamic okLadd ❑Mi Pmparty Owar Name Jeff Menlnres
❑Mmatm, 0Im'.n ❑Taw Win OOdc
Well Svetl Addrms )Ot NE Haven lake Dr
Camnmdoe rym: Mawr City Tahma County MRsOn
O Nmw ❑0 ee OAiwe ❑kw ou"agl
I ODxpmq Odia gbr OilingALM O ❑Watlry T.Pernl No, 2233D50-003/5
M®is:Diolrolimq 8 u,b Mail A. WMavriarce appmvd hrlUasmlll O Y. ERNo
DWLefaaglmd wel 237 L
DelsLmdmw: Wall Ifyes,whet was the mamma fore
lYiy lies Obnum Frain To Thicicamas Bart PYC Wa11d TMmd
(M ❑ e in. U MgL Ml ,m O I o M I ❑ Lacmion Ima inslncXmsm pege2): O W WM W❑E
❑ ❑ _ire ❑ I ❑ ❑ I ❑ NE A-Y.oflhe SW V.;Smlion 30 Tmame:ip 23N Ruye 2W
❑ 1 ❑ _in. _ _ _in. ❑ 1 ❑ ❑ I ❑
} O ❑ _w. _i . ❑ 1 ❑ ❑ I ❑ IAtitude(femplc 47.12F45) 47A5588
S PmLMa: ❑Ye MNo Typofprbrrtmtl LaneitWe(Example:-120.12345) -M2 0854
!C} Nwofpmromlias_ Sbeefpsbegsm_:.y_u DdIkrY LoB/ComtnaXon or OeeommiWoo Primed..
Palo imr_g.b_Lbulo.rpamdv[xa Panbtmo:nrm66Y•^I^r.clmeerv.iv orewerYl W.Yuelmv,.od rb Wedd
ebmeofrhe mmeNl m naR ley<rpeneo•reJ,xi:h.r leenmeeoay 6w erAUge of
Bembr OYn mNe OK-PSYV C' UryL_L lobmbiw. U.o tldiriwul.M1vnirrcryuy.
tp Mm:achvvY Nmw MoYtta Material F. To
22 Umb_ 91dv_v.Rm _Aro_h. 8ramin RIXEOW und!and grawl,fill 0 2
fr Dibwr_ Rlm.s ia&m _Lan R. Britian filly sand and pravel 2 28
GM de santl and grawl 28 48
BeeMRlrpmb❑Ym ®Ne s®ofprk mrrbl_in' Raovm claybound sand and ravel 46 78
Mrd•b fWwd Rao_Ln_fl
❑NO TowhrdmLP18 fl Burial rally a 78 0M•Xdalr�kxel BaradedliM RaDwOtl vain
mand antl and ravel g3 108
c Y. Blue and!gray tl Mb santl and ravel,etlll 108 131
Oitl bp.mummiemmSbw•o-d O ONo
TypeorwN/ DepLofrrr BraNm chry aaM and ravel 144 1M
Me:mdetmJing se.uoff G clay,sand!and ravel 144 155
C e.mP: Mmuriavr.N.m typo; Raman clay. 8 a ,sand and ravel 155 18
! HP._ No mamd.,&_fi. DbpdB rbn_PFm Bf sfi 9aMand nVN 158 222
8 Raman sal sand and revel,wet M2 222
Wrcr 4relu LmdamSev elmnk..mm man be Wd 42J L Raman sand eM revel,water 2M2 Mail
Y Siakup o,1,,e, 17 uabp 1_, R.ebme pmml•vna
F 5bd.wmer leM ,7e le,I'm —mere wing Dan trans
Maien Rebwe_IRa Wnwry ircM1 Uw
Me.i.nwe:nurwemllm by (wp.Wq YJ
Will Team
Wb•pv¢iy ran Prnfmrdl®Nit UY. — ywM
r Yield_gym wiro_a.draadma ala_Ma.
ZO Yield_gym with_tL immYw asr_am,
Yield_man whh_R.dreadew ab_her.
Rmow rY cm.mme-pro whir:prim b mmd M-want amid:m•meed Ran xaa
y Time
r brat)
Ti W=r1arJ T= W=m lab T= W=1wml
W
gm,..Pun:pir8nv
a•iknm man wah_6Mdme•Ree_M
Air rear 20 man win•Immr 220 R.61.5 Y• m. 1I1lg25
Aneaun Mw_mm
Tnnpenmm ofwmn 50 .P wr.tlevw'.Irmyismrddl oYb BUN Dam 1/11/25 Canpltld Due 1/15l15
O WELLCONSTIRUMONCERTWICATION: ImWrmkd arWWaaap rmp:auibility fan edelrrNlim oflhU well,and iu OpmpliuNe uilh Ml WMhinglmrsbl
cmarudion audaUs.Materads and and the infmmmkn repand above art true to my ban,kmotdw ad belief
9 Order❑Trainee,❑PE-Prins We,1-h ROpp Drilling Comlmm'Armtlaa Drilling Inc.
Sig mum, Address Po Box 17M
IJcmx No 2874 Cary Slme,Zip Magian.WA g85B4
W'fRAINEE:Spvum'a u.AlWilig, Cant..,.
Spmsara SammNrt Regi,lnlion Na.MCADDIONK1 pale 1/iw5
ECy MO.l.20(ReY00/I8) f/�wr nerdlAAdaumnlia an alkrnakJannl.ylmrs rnlllM Warr Retanrrea Pro;rnm a1360-dOh68JI.
Perzau rvllh A[arlxg tau rant tell llffor lVmlrirrgAmn Re(uySnvkr. Peeraru viT nnprrcL dimdlllsy ran eall8J7d33-6311.
WATER WELL REPORT CORRFNT
orspale P'may-Eolep,a"mff-owner,0 sets,-dater No0ee of intent No,WE24755
ECOLOGY Coestructiun/12eeommission('k"in circle) Unique Ecology Well ID Tag No.BJM 924
97 struetion Went RigM Pcenit No.
❑ Decommission ORIGINAL INSTALLATION property tTmn Neme7lm Liewln
Notice o IntewNsunber
PROPOSEDUSE: 0 Dommdc ❑ kAuldal ❑ Mimiapl Well Street Address 700 NE Have.Lake Dr.
❑ Dswaa ❑ ongeom ❑ Test wdl ❑ me City Tabuve County Mason
TYPEOFWORK: tTww'snumW ofwdl(ifmaeNm me)_ Location 5WI/4-1/4 NEI/4 Sec30 Twn23 R2 EWM ❑
N Ns%,.V ❑ R ssq ei meshes'0 Doe ❑ Bond 0 Ddvm
❑ DrepenW ❑ Cade ® Rotuy ❑ Jdld 0.L r 5011 REQUIRED) Or
WWM
DIMENSIONS: Uamdnofwe116 movo,dousd262fl.
Leon ovg
ofwm am well262 h. LW Deg _ Let MiNSec_
CONSTRUCTION DUAI1S lung Deg_ Long MirdSc=
Can, ® wdeed 6" Di—fire-tIlLoo 257 fl.
losuned: 0barsedled! " Dom.fiam=fl.le_h. Tex Dsscel No.(Reglurt0)223305000333
❑ lMvtled ' Dian.From fl.to_&
Pakndom: Yes No CONSTRUCTION OR DECOMMISSION PROCEDURE
Type orperfm+a coed Famnion:Desu3e by color,chanter,e,..f mmriel ad strame,
SITEefpe6_io.q_io.epdm.af pats Dam fl.m_g ad to kind mdmurt oflhc matarid in cash strnme penetrated eaha
�r last one mq for each stage of infoemetion. (USE ADDITIONAL
i Sapse: 0 Yes ❑ No 0 R-Pee Loudu 255 SHEETS T NECESSARY.
d Mmufumm's Nano Allay Maebiee Works MATERIAL FROM TO
Type stainless Moil No. Top Ball 0 2
} most.5slm ae 12 epm 257 fl.to 262 it Bmwn 60 2 176
1 N— Slnl six Dan Am ft. Gray 60 176 239
G—VFnnr,,aA: 0 Ya ® No Siaofpaypsmd_ Brown fill 210 245
Matanspkeedfnnn_fl.k_fl. Sand&gmvdwitkmw 245 262
Serka Sal: 0 Yee ❑ No Towtmdeph5jIft.
Mnaid ottdk colBt i
tp Didmyswmnam unuWkwelaP D Ya ® No
iI�SR Typsasoneol Ikgb Msbw
rump; ooss sereN
PUMP: Mamd�wrar Nmee Greedfoss
Type:sub N.P. 112 —
WATERLEVELS: I�vdawf elmdw abovemeen wlerd d.
Smicle,s 2ee wkp of well Dne
An wpmenneu2_IM.pv Nuve wA Date
Anaeowsurecennsfiedbym.WELL
W¢LL TESTS: Rawdown ie amnml weer keel is Inwemd Wow code Iswl
Wma Wmpato's"? 0 Y. ® No Ifyes,bywhan)
Ywld malArn..wilo lowdown after,
Yidd'. onAnin.wd, P.dmvtlown efla_hn.
YNW'._gsLonum ni_fl.dnwdown Ner_hn. V
aern,ery dnu(nme beenmzery when pwnp am�odf(wmer(e"I mew,rcQ/rose
well mPawmnlerell )
Time Wercr Lend Time Water Leml Time Wtlw L vol
Drlsoflm O
�j Bdla nn�pllmin.withl fl.dnwdownW1M1n.
v Ainen_gclam onto vmenn_fl.fa_hn
Aneim now_eom. Dec io
Tanpvaeneofwakr_Wa atlaniW emlysismmeP 0 Yes 0 No Stn Drta B/10/16 Completed Date 8(18/16
WELL CONRrRUCflON C MFICATION: Iconseuecd and/or acceptres,eoibilily for comhuetion ofthis well,adds complbnce meith all Washingtn well
construction silMards. MatmNs used end the information reported above as ime tomy but lmowWp end belief
0Ddlltt❑E inear❑Trainee rat Ct Pgb Glide ,Comas, Davis Drilling
Drillu/En ulna?mime Si an N 'rt Add. 340 NE Davia Farm Rd.
Drillerwnelna Lieeme Nn V116 Citv.5tnW2ip Eelfeir WA, 98529
IF TRAINEE:Dtilter's License No: Connector's
Dnller's Signenm: Reginre6on No. DAVISDH10OA Date Aue.2016
ECY 050-1-20(Rev 02-2010) To ralua+f ADA aceommodmon insludng mawwle in a formatjor rbe vuualty impaired,call£cokgy Wmo Ruouraer Program
m3601402L812. Permwhh inyu.ed herring may call Washington Relay Service at 71L Persmrvwkkspeech Nrnbdkyahrycall AYn827d33-634!
...
+ N!ATEB WELf. .REPOBT "�^"�"°°"
na.
d4A1t Or wax.
WAMN OF C Lc}_----... _ .__. _ ._. u SSdtu r _r'.�3�.,
re
g tl0!{ FY)! p IY J•e pd. " n r.r.`+o (14) 9"" I'm
•, , �1•d wr,q+•a or. . o .«. eer., a--• - rvl r -
Yat g • . ' �"..�+ L
F
bond
ap a
...0 bw n
p7i'�IJdL,' 4bR ' rer a Q y.
� _, kb111���6�_Yp�_0.
:et 1'p
�/►�M�^t�i' �p� � drat_/LY_s — t�;�eld.�is'drrrrr.rr,.w .w+ nea W4W ---�--
W—ir r dlm
Iv
15�1 61,'
44
��yy�".•.,�11!I�rawlw Y, +eyw�o.a�cs �py [ V �
N! M�YN ii'i M�tl 1.w1 Mpl Y 11 fL:�Q_.IILQ.
Abeb rl� Trp Ile d►Y)�..l�bemt
.��� M • ' a.M�ae�n Yrr ,� wZLL DO6ld{'8 O'PATOmiTt
w.W *A b�a "kn lodn.oaJM Mau� � � l•ce•l b
• M 1IMe eIn �ehellwegrmr all IOW lnY
�}Ir11YP
1pr car Llew srw relw I..a� >v.e carer rwr NAIR(j�il£f.�QS`__w�Ll..iJ_ee.l.�.4.h i_ '
[elo
PROPOSED NUWATER
\\\\ &1500GAL. PUMP TANK
HAVEN LAKE (50'.TO LAKE&WELLS)
� 1 \
AT,\T
EXIST. \ \\ o® \ \1
WELLMST
CABIN ` \\
/ \ \ EXIST. WELL \
DOT \ (WAIVER REQ.) \\
Q� CABIN ♦ \
R75' �1
---- \ \i I FUTURE EXIST.HOME
\ I
30' DRAIN SETBACK / LOCATION \ cARncE \ I
(NO FOUNDATION/FOOTING DRAINS WITHIN \ \ ( v
30'DOWNSLOPE OF DRAINFIELD AREAS)
PARKING Q'
10' BLD SETBACK
LARGE STUMP/TREE
PROPOSED 4 BEDROOM
PRIMARY& RESERVE
�O
'CONNECT EXISTING CABIN &
EXTEND SEWER LINE UP HILL FOR
FUTURE HOME CONNECTION / \`(
i
N®O
EXIST. WELL A 10 "°"°N
(WAIVER REQ.)
. AN CFIARGEDATTALL SIGNOFOFINSFFEENALL
BE OHAROED AT TIME OF INSTALLATION
CUSTOMER: TEST HOLE I, TE HOLE 2 TES(HOLE 1:
PIONEER DIGGING, NC- PARCEL 4 °' 0-12 DIST DI8 DIST. 045 CSL
12-36 a I8-52 G5L 45 NtOTT/R45
SEPTIC DESIGNS ADDRESS: 41 RHODODENDRON 36 NIOTT/R36 52,\ TT/K52
3083EMASONBENSONRD. GRMEVIEW,WA98546 DESIGNER: AM LPAYSSE
OEHGE-3604261803 FAX-360427-2353 SHEET: SREPLAN SCALE 1'=40' �• uaveuxm^Fawxuas rwenuceeuxnw
Pioneer Digging Inc.
3083 E. Mason Benson Rd.
Grapeview,WA 98546
STEPHENS,JEFF&MELISSA 3/21/2025
3715 103RD AVE CT NW
GIG HARBOR WA 98335
To whom it may concern:
I am a Septic Designer working with your neighbors on Haven Lake,Cody& Stephanie
Powell,on a new septic design. This letter is to inform you that the Powells have made
application for a waiver to locate their septic drainfreld 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. The proposed septic system will be pre-treated prior to disposal w/an aerobic treatment
device. 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.- 360-426-1803/360-507-1546(cell)-Alex L. Paysse/Designer
Mason County Health Department- 360-427-9670-Ext. 400
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