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HomeMy WebLinkAboutWAI2025-01925 - WAI Health Waiver - 4/10/2025 415 N.6'STREET,SHELTON WA 98584 ,', MASON COUNTY SHELTON:360-427-9670,ext 400 COMMUNITY SERVICES BELFAIR: 360-275-4467,ext.400 �: �.-• ELMA: 360-482-5269,ext.400 Building,Planning,Environmental Health,Community Health FAX:360-427-7798 A alication for Waiver or Appeal ECEVE Amount Paid: Receipt Number: ZUZS 6 25 ► APR 1 0 2025 WAI �Z o(x)2J� li By Instructions: 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 Information Name of Applicant Charles Butros Telephone 360-427-7341 Mailing Address 342 SE Nelson Rd City Shelton State WA Zip 98584 Parcel No. 2 2 1 2 7 -- 4 3 0 0 0 0 0 Site Address 728 E Sunset Hill Rd, Shelton, WA 98584 Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Onsite: Class A Waiver 0 Food Sanitation Requirements ❑ Onsite: Class B Waiver 0 Group B Water System Regulations ❑ Onsite: Class C Waiver 0 Water Adequacy Requirements Onsite: Location, WAC246-272A-0210 0 Building Permit: EH Review Policies O Onsite: Holding Tank, WAC246-272A- 0 Appeal: Enforcement Timelines 0240 ❑ Appeal. Departmental Determinations O Onsite: Contractor Certification 0 Other Requirements Description of Waiver/Appeal (include justification. additional material may be attached.): Reduce setback from proposed well to proposed drainfield from 100' to a minimum of 75'. Mitigation is that proposed septic meets Treatment Level B and the proposed well is not directly downhill of the drainfield. There is a large driveway with compacted gravel in between the proposed drainfield and the proposed well, reducing hydraulic susceptibility. Local well logs show multiple clay layers (see attached well logs). Applicant Signature: ��11/`L-1-U Date: 4-9-25 , *Sc-_* R iced 8'13i2018 This form may be scanned and available for public view on the Mason County Web site. Page Iof2 PART 3: Public Health Evaluation (Staff Use Only) t (9 C- 1. Type of Determination Required: Type of Onsite Waiver (if applicable) Appeal /�(/Vaiver 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: r O C A( fttJe . 7 tC) ( /e J r 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board ❑ Environmental Health Manage 5. Mitigating Factors: crl/-e (( l C 75 S ie 51 re — k_ sk, A,ec....<-by c/(p-t(1 10 44,4---Ii ez.e j 0 (4 Ok:t(vii..elt (4y2r") Ceti t( &V� C l s© �- 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: to U\./75 \ -- Date: Zi(--aS PART 4: Determination of the Hearing Official ilL 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: Health Official Signature: )V---- Date: VI--.n 7R :ed S 1 3v2018 This form may be scanned and available for public view on the Mason County Web site. Page oft WATER WELL REPORT t.,...ivag DEPARTMENT Of Notion ofIntent No. WE55684 s(t C EI •• ECOLOGY Unique Ecology Well ID Tag No. BPF200 Type of Work State of Washington �� � 2tt Site Well Name(if more than one well}: © Conatruceion O Decommission ==_.N Original iaatallarion NO1 Jvo. Water Right Permit/Certificate No. WA State Department Proposed Use. l]Domestic 0 Industrial 0 Municipal Property Owner Name Rachel Clark fit#Ecology 41� tRL3 0 Dowateting 0 Irrigation CI Tcst Well 0 Other_ ) Well Street Address 121 E Passage View Rd Cgnstrmction Type: Method:pCity Shelton County Mason "New well 0 Alteration ❑Driven O Jetted 0 Cable Tool O Deepening 0 Other 0 Dug Cal Air- 0 Mud-Rotate Tax Parcel No. 22127-76-00070 .Dimamtiom: Diameter ofboring 6 in.,to 154 rt. Was a variance approved for this wall? 0 Yes 0 No • • • :Depth ofcompletcd wen 154 It If yes,what was the Variance for? _ Construction Details: Wall Castag Luxes Diameter. From. . To Thickness Steel PVC Wsided Thread C3 y,�y ttZ or EWM al. 1 0 .g " . :jn .0. . . .150.6 .25 in. al I 0 O I O Location(see instructions on page 2): 0 [ ❑ . . . iR in. O I 0 ❑ 1 0 SE Y.%of the SE t/+;Section 27 Township 21N Range 2W DID: in: _ _ in. O 1 O DD Q 0 in. in ❑ t ❑ 0LatiCtde(Example:47 12345) 47.27573 N • 1 Longitude(Example.-120.12345) 122.91379 W a l Perforations: O Yes nil No Type of perforator rued i a Driller's Log/Construction or Decommission Procedure y Na of perforations bet of perforations is by M. Formation:Describe by color,charactet,size of material and structure.and the kind and Perforated from__fl.to-ft.below ground surface nature o f the material in each layer penetrated,with at least one entry for each change of to:: Screens: E Yes 0 No El K-Packer Depth 148 ti. information. Use additional sheets if necessary. n Manufacturers Name Alloy Machine Works Material From To c Type Wire-wrapped Model No.Diameter 9_ Slot six.016 in from 149 ft. Brown silty line sand and gravel 0 8 to 154 ft. o Diameter Slot size-in.from -ft.to it Brown fine gravelly sand,siltbound 8 8 3 Brown fine sandy silt 13 16 o SaudrYilter pack:0 Yee lie No Size of park n•.atetiei in. • 16 24 Materials placed from ft.to fr. Gray peaty silt F Gray sticky clay . . . 24 39 '6 Surface Seal: fit Yes 0 No To what depth? 19 ft Gray gravelly sandy clay 39 44 F. Material used in coat Bentonite chips Brownish gray clay,peat 44 47 Did any strata contain unusable water? 0 Yes J No Gray hard clay 47 56 `D Typo ofwater'? Dpthof strata_ 56 65 Method of sealing strata off Gray silty day - 56 68 `o Gray day,veins of gravel O Pimp: Manufacturers Name Type: Gray fine to coarse sand,fine to medium gray 68 xP. Pump intake depth: A. Designed flow sale: ! gravel,heavy,siltbound 81 sr Water Lewis: Land-surface clevstiou above mean sea level 120 !< Gray gravelly silt 81 86 C Stick-up of top of well eating 1.8 ft.above ground surface Gray fine gravelly sandy silt 86 117 Static water ievel 104•S fl.below top of well easing Date 812/24 a, Gray fine to medium sand and gravel,siltboutxi, 117 Artesian pressure lbs.per square inch Date 136 P. Artesian water is controlled by (cap,valve,etc.) moist L. Fine to medium multi-colored silly sand,gravel, 136 o Well Tests: wet 141 pumpingWas a test performed? El No 0 Yes c=a by whom?— Brown fine sand,fine to medium multi-colored 141 Yield gpm with_fl.drawdmvn Mier bra. roundgravel,water bearing 154 ti Yield -gpm.with _ fl.dl.w&w.wafter life t9 Yield gpm.wil t_ al.dpiirdo*d.afkr lus. i Black medium silty gravel,sharp,tight,weeps , 154 155 3' Recovery data(tine �eroarhenpumpi3 taint off' water level measured front well i O . . . .lop2Qwater level) 95ute Water Level Time Water Level Time Water Level O '' Date of pumping test o __ Bailer test gpm with_El drawdown after_hrs. `y Air test 20 gpm with stem set at 120 P.-for 1 hrt .Date 8/2/24 Arse,;a.,now sc.r, B Temperature of water 52 °F Was a chemical analysis made? 0 Yes E1 No Start Date 811/24 Completed Date 8/2/24 a. It• WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well y construction standards.Materials used and the information reported above are true to my best knowledge and belief. - SiDriller 0 Trainee 0 PE-Print Name Cory Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 3441 T v" City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No 205 Contractor's Sponsor's Signature / Registration No.ARCADDI098K1 Date 8t2124 ECY 050-1-20(Rev 0 /18) If you need this document in an alternate format.please cull the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call877-833.6341. .lert Original and Ecology copy With WATER WELL REPORT Application No. .cond Corpartmant of Ecoingy turd Copy-Driillers Copy er's Co STATE OF WAIIIIILNOTON Permit No 1) OWNER: Name_ •-� r�rr-..... -- Addr..t.�l7?•7...I.;.eZ__S- ..RI N.. .41........ ....._............ 2._ 2 2) LOCATION OF WELL co .._.7t.1..4 r+,_. -/Y�_k F sec. 'Z.. Tat.. x.. Lt..oet wM. V wing and distance from section or subdivision corner _ _ '^ - di —rat ill 11 R PROPOSED USE: Domestic 'Industrial 0 Municipal ❑ (10) WELL LOG:so Irrigation 0 Test Well ❑ Other 0 loemttiDescribe by Color,character,size of material and structure,and show of needle?:and the kind and nature of the materiel in each is show penetrated, with at least one entry for each change of formation, 9 i TYPE OF WORK: Owner's number of well - - )r. (if more than one).... ......_._......._........_._..._.. MATERIAL -TROD[ I To 71 New wall Method: Duo 0 Bored ❑ Deepened -- `� I 0 Cable 0 Driven 0 - 5 Reconditioned 0 Rotery� Jetted ❑5 t 1 l - •.) DIMENSIO i, Diameter of well V rt inches. Aar ! 6 3 Drilled._.../ -•.••ft. Depth of completed well...lire _.-._._.t. A. e •. • ♦ .- 3 ) CONSTRUCTION DETAILS: .t f a — . Casing installed: Diam. from N. to .........._._ ft. _ -_ ' , �17i• . _ Threaded 0 _" Diem. from .-..._..._.... ft. to/ ... ft. s s o f ille LI We] Y- _ n ...4...._" Diem. from -f -. . . (Dear-r_ ft. - ^ q,w+7 3 Perforations: yes ❑ No$' -- - - I5 Type of perforator used .._._.___....----_ice._.._. SIZE of perforations ..........__.....----...... in. by in perforations from ft.to ft. I t a perforations front ._._......_._.._., ft• to ft 3 perforations ft.perforations from ft.._..........__...._ to _._.....__._....... 7 3 Screens: Yes❑ N W Manufacturer's Kame...._..._. . ......-._--._ -- Type........_..................__._.. -_....__ Model No ....... ---._._ -- 3 Diem...._.._....._ Slot size ...._ from ............. . ft. to .._...__.__ ft. .. .. --- Diam. Slot size ...._..._-. from ........_..._. ft. to ft. - -- I - -- 6 Gravel packed: yes 0 Na ' sire of gravel: _ ______ ;7 1 —� Gravel placed from -_................._......... ft. to............_.................. .. ft. .::_ •N — SJ Surface seal: 1 se No p d� ss. f--_ _ — r w t Material used d }seal ..._........_...._..... } -_ _ Did any strata contain unusable water? Yes 0 No❑ -. __-.--- ----- ) a Type of water?.. ................_............. Depth of strata.....__......__.......... Method of seating strata off :) PUMP: Manufacturer's Name_ C#_... _.r4e.k i._ ---_- .. t 3 Type: . S!'L._ H.P... — - - - WATER LEVELS: I.Itnd-sttrfeee elevation �) above mean sea level — .... .._. -._..._— - asc level ..... r�............_...._.......ft. below top of well Date....•. •tesian pressure ..................... .lbs per square inch Date....................____ Artesian water is controlled by — --- - ,J (Cap, valve, eta) —_.__.- Drawdown is amount water level U - Q _.._._+__ __.._-_ I) WELL TESTS: lowered below static level �w� 1911... Completed..�!c�.Q.-••- -••••. Work atazceapt�.+...-_.__._. ifirt -s a pump test made? Yes 13 No If yes. by whom?_ -......•....... U .eld: ;al./min_ with ft. drawdown after hrs. WELL DRILLER'S STATEMENT: __ This well was drilled under my jurisdiction and this report is •. " true to the best of my knowledge and belief. 1 ^covery data (time taken as zero when pump turned off) (water level measured from well top to water level) TIAME.. • 1 Time Water Levet Time Water Level i Time Water Level {perso yp n. ,or torpor (Te or print) Address ., Ai. ... 4,/....,... _ Date of f / (Signed].. ;after test gal./min.wit s. drawdown after_... -.-_....hre. (Wellr -rtesian flow........_.........._..._..........,......_-..g.pm. Date............................---- •-__---• itTiC.` 'cmperalure of water was a chemical analysis made° Yes 0 No❑ License No.dmorce Date_. ................. 1 n. (USE ADDITIONAL SHEETS Dr NECESSARY) 41$110-s •.v 0541-20