Loading...
HomeMy WebLinkAboutWAI2025-00024 - WAI Health Waiver - 5/12/2025 ` _ 415 N.6th STREET,SHELTON WA 98584 :: . di% \r MASON COUNTY SHELTON: 360-427-9670,ext 400 COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 ELMA:360-482-5269, ext.400 Budding.Planning.Envitnnment.a!Health.Community Health FAX: 360-427-7798 Application for Waiver or Appeal Amount Paid: Receipt Number: Cif 2025 00024 Ny 7 ��1. WAI RFC� S Instructions: ��r0 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 Jami & Jimmy Kaneshiro Telephone 360-292-0909 Mailing Address 15016 SE Diamond Dr City Clackamas, State OR Zip 97015 Parcel No. 3 2 0 2 2 2 3 0 0 0 1 0 Site Address XXX E Hillcrest Dr, Shelton, WA 98584 (across from #250) Subdivision Name and Lot TR 1 OF GOVT LOT 1 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 ❑ Water Adequacy Requirements ■ Onsite: Location, WAC246-272A-0210 0 Building Permit: EH Review Policies ❑ Onsite: Holding Tank,WAC246-272A- 0 Appeal:Enforcement Timelines 0240 0 Appeal:Departmental Determinations ❑ Onsite: Contractor Certification ❑ Other Requirements Description of Waiver/Appeal(include justification, additional material may be attached.): Reduce setback from stream and well site to proposed drainfield from 100'to a minimum of 75'. Mitigation on well setback is that system meets Treatment Level B and well is up-slope of drainfield.____ Proposed septic is NuWater BNR-500 to shallow pressure with timed dosing. Mitigation on reserve drainfield is that the septic can meet Treatment Level A with the addition of a Salcor UV light. Applicant Signature: 1 Date: 5-9-25 a, irvsbo t 6, s??.,1,-.8,-vrc-o r_o-> r Revised 8i 13/2018 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 PART 3: Public Health Evaluation (Staff Use Only) (VCq f 1. Type of Determination Required: Type of Onsite Waiver (if applicable) Appeal )(Waiver None required Class A Class B Class C 2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/ Standard revision): kr Z ' • ?72.A - Z10 3. Nature,, of Appeal: b (ledcce, itten(Wion ka%torll�tl S� yb e� AO I for cG W I f✓lyrn !00ft 1-0 not 1935 Mort , 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director 0 Certified Contractor Review Board 7 Environmental Health Manager i 5. Mitigating Factors: 1 J �0�, ty, is Yr,`N+urY d!'arYlf 1°{d • ( aL�A f s Calk), f r�K • i /iZ01 S� b v o t ,?5CILc%r' mole: w�flt. [DO f f ott ace_ ter" - 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy as been submitted. �(' Staff Signature: Date: fiZ3 Zr(> PART 4: Determination of the Hearing Official la-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: 0 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: 1/L 1/ Health Official Signature: f Re,i5ed&13/_U1S This form may be scanned and available for public view on the Mason County Web site. rag` era , F - • r5 f' =" i lM (p; , ; 5i PZ�-3 � :, 7 3 Clez.ct i O3 500 C?_oa a^ems^.r�^{ *Z: 0—2 I G G?Tv aR'= `1 0 IN) tC,ntvR OOG Ceio a_^�Cl'z=be= sc : (; 7% = i t r10 II . r ` E i Cl I .• J ,C�, 1 ' n � • F�K � � J. E ( T S��Vr 361—'� ) . I , ( . 1 i i _ • M p-�NI :;0 A sp— i 1 0 � L T Q 1 r g . ,,--___,, i -N \ -- N coor / � / (. 73' / >;5k p_-:.'<<,"-:ccR-. o a j, 1: QL✓-- =L./ :-,Q. Prt2C>rLY'52.E9?-2?-oEe ; D i H-t L1GgG-S— D P_ v y, � 1 S t-[-E•LTo nJ i s,.:Gr g 5 jt if AA ; t+ '@.Zt;i. 7s. it L00 S-e-`Ao6,-t-1� Yr s,6u :s ;.y, l; V4'� O? PAULA JOY JOHNSON:-- . UCISNS8 figt"C k ,J' _ W''_ t-x�- -\"' 1� EXPIRES 9%'1 L./Z.(p c)„4-1e,,\ -4--e-4- rC\--"W-, .\-.o �.zSrl, S-1 - ZS WATER WELL REPORT DEPARTMENI Of Notice of Intent No. WE45927 t " I ECOLOGY Unique Ecology Well ID Tag No. BNX185 Type of Work: "01.4.1State of Washington Cl Construction Site Well Name(if more than one well): ❑ Decommission ' Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: O Domestic 0 Industrial 0 Municipal Property Owner Name Charlene&Charles Maxwell__ 0 Dcssatering 0 Irrigation 0 Test Well 0 Other Well Street Address 131 E Hillcrest Dr Construction Type: Method: EJ New well 0 Alteration 0 Driven 0 Jetted 0 Cable Tool City Shelton County Mason ❑Deepening 0 Other ❑[hug O Air- 0 Mud-Rotary Tax Parcel No. 32022-76-00020 Dimensions: Diameter of boring 6 in,to 159 ft Was a variance approved for this well? ❑Yes ❑a No Depth of completed well 159 R. If yes,%that was the variance for? Construction Details: Wall Casing Liner Diameter Front To Thickness Steel PVC Welded lluead f3 I ❑ 6 in. 0 iss 0.25 in. © I ❑ EIO Location(sec instructions on page 2): al WWM or 0 EWM ❑ I ❑ in. _ _ _in. ❑ I ❑ ❑ I ❑ NW y,-K of the NW '.;Section 22 Township 20N Range 3W ❑ I ❑ in _ _in ❑ I ❑ OID • ❑ I ❑ in _ _in. CII ❑ 0 I 0 Latitude(Example:47.12345) 47.213010 t — Longitude(Example:-120.12345) -123.054972 8. Perforations: ❑Yes l l No Type of perforator used Driller's Log/Construction or Decommission Procedure tv No.of perforations Sizt of perforation_is by_in. L Formation:Describe by color,character,size of material and structure,and the kind and Perforated from ft to_11 below ground stuface nature of the material in each layer penetrated,with at least one entry for each change of d information. Use additional sheets if necessary. • Screens: ❑Yes WI No 0 K-Packer t� Depth ft. to Manufacturer's Name Material Front To - Type Model No 0 8 } = Diameter_ Slot size in from _n Brown silty clay with gravel.to R. 8 18 o Diameter Slot size in front _fl.to ft Br0\'m silty sand o Brown medium sand,gravel 18 22 t Sand/Filter pack:❑Yes ;50 No Size of pack material- in Brown fine sand,web 22 68 O Materials placed front n.to n. Gray fine silty sand 68 74 I- Surface Seal: fib Yes 0 No To what depth? 19 n O Brown fine silly sand,wet 74 78 `F- Material used in seal Bentonite Chips 78 111 Gray silty clay Did any strata contain unussbk water? 0 Yes O No o Black silty sand and gravel 111 117 Type of water? Depth of strata Dark brown peat and gravel 117 120 V Method of sealing strata off c Gray silty clay 120 128 c • Pump: Manufacturer's Name Type: Black silty sand and gravel,wet 128 137 H.N._ Pump intake depth: n. Designed note rats: ppm Multicolored gravel,medium brown sand,water 137 149 Rater Levels: Land-surface elevation above mean sea level 130 ft. Black gravel,black sand,water 149 159 sStick-up of top of well casing 1.5 fl.above ground surface 4- Static water level 100 ft below top of well casing Date 1/21/22 4 Artesian pressure_lbs per square inch Date - OArtesian slater is controlled by (cap,valve,etc.) r_ L O Well Tests: Was a pumping test perfimned? 0 No 0 Yes ' by whom? O Yield_gpnr with_n yyEF ■drawdow n alter_hrs. E'V E D Z Yield ppm with ft.drawdown alter hrs. , ` W Yield ppm with ft.draw down after hrs. 'tta " APR �+ 2022 Rccoveq data(time=zero when pump is turned off water lest'measured front well -p top to water level) Time Water Level Tune Water Level Time Water Level Y\A/A State ` epa Ht Tsof Ec&1ogy ( O) 1 ✓ 1 W 4- Date of pumping test 0 Daikr test gpm with_ft.drascdoscn after hrs c Air test 50 ppm with stem set at 140 ft.for 1 hrs. Date 1/24/22 Artesian flow ppm Temperature of water 50 °1 Was a chemical analysis made? 0 Yes EJ No Start Date 1/24/22 Completed Date 1/24/22 L a • WELL CONSTRUCTION CERTIFICATION: 1 constructed and/or accept responsibility for construction of this%tall,and its compliance with all Washington well n construction standards.Mate'ittls used and the information reported above are true to my best knowledge and belief tv t E Driller 0 Trainee❑PE-Print Name Josh Koepp Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No.2874 / City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsors License No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 1/24/22 ECY 050-1-20(Rev 09/I8) if you need this document in an alternate format,please call the Water Resources Program at 360-107-6S72. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-S33.63.41. ti O ?,1rnflles S' F O WATER WELL REPORT .,..t a ,)1,1,)1V,G. N CURRENT ECOLOGY Original&1' copy-Ecology, 2n°copy-owner, 3 copy-driller Notice of Intent No.W280107 �r Construction/Decommission Cx"in circle) } 11 Construction Unique Ecology Well ID Tag No. BCA 527 N D commission ORIGINAL INSTALLATION Water Right Permit No. s Al' 53 (fl Notice of Intent Number Barbara Andrews ++ Property Owner Name C PROPOSED USE: ❑x Domestic ❑ Industrial ❑Municipal O ❑Dewatcr ❑Irrigation ❑Test Well ❑Other Well Street Address 1251 E Leeds Dr. C TYPE OF WORK: Owner's number of well(if more than one) City, Shelton County Mason O ❑x New well ❑ Reconditioned Method: ❑Dug ❑Bored ❑ Driven R ❑ Deepened O Cable ❑Rotary ❑ Jetted Location SW 1/4-1/4 NW 1/4 Sec 22 Twn20 R 3 EWOM 0 Check E DIMENSIONS:Diameter of well 6 inches,drilled 84 ft. (s,t,r Still REQUIRED) ,vWM 2 One Depth of completed well 84 f O CONSTRUCTION DE;TAILS Lat/Long Lat Deg Lat Min/Sec t C Casing C3 Welded 6 " Diam from +1 ft.to 79 ft LongDegLong Min/Sec Installed: ❑Liner installed Diam.from ft.to R. 0 ❑Threaded " Diam.From ft.to ft. Tax Parcel No.(Required) 32022-23-90023 y Perforations: ❑Ycs ID No CONSTRUCTION OR DECOMMISSION PROCEDURE 1- Type of perforator used Formation:Describe by color,character,size of material and structure,and the kind and 0 -- -SIZE of perfs in.by - ..in.and no.of perfs • .from ft.to ft. nature of the material in each stratum penetrated,with at least one.entry for each change _ .- of information. (USE ADDITIONAL SHEETS IF NECESSARY.) Cscreens: ❑x Yes ❑No [K-Pac Location 77 MATERIAL FROM TO Rf Manufacturer's Name Johnson 0 2 T,pe stainless Model No. Top soil 2 14 RI y Brown clay with gravel f+ Diam.5 Slot size 12 from 79 fl.to 84 fl. tQ Brown sand&gravel 114 135 CI Diam. Slot size from ft.to ft. Sand&gravel with some water 35 150 Gravel/Filter packed: ❑ Yes E No Size of gravel/sand Sp 158 a.) ft Fine gray sand with water Materials placed from 4-1 _ ft to Gray clay with gravel 58 69 — Surface Seal: yes C] No To what depth? 18 11. Gray sand&gravel with water 69 184 a�• Material used in seal Betonite , CI Did any strata contain unusable water?. ❑Yes Q No 7-1— LType of water? Depth of strata . . al Method of scaling strata off • PUMP: Manufacturers Name Goulds 1 - Type: Sub H.P. 1/2 WATER LEVELS: Land-surface elevation above mean sea level ft. VTStatic level 18 tt.below top of well Date 0 Artesian pressure lbs.per square inch Date O Artesian water is controlled by (cap,valve,etc.) 13 WELL TESTS: Drawdown is amount water level is lowered below static level ' En Was a pump test made? 0 Yes ID No If yes,by whom? O Yield: gal./min.with ft.drawdown after hrs. .Li O Yield: gal./min.with ft.drawdown after hrs. O Yield: gal./min.with ft.drawdown after hrs. N"O ••X LLI Recovery data(time taken as zero when pump turned oft)(water level measured from well _ X rn 4— top to water level) r^3-` O Time Water Level Time Water Level Time Water Level - 52rn 4I =—4" I I - �oq r_ E o trim Ia T� . . T C) IC) LDate of test CU Bailer Test 16 gal./min.with 45 ft.drawdown after I hrs. r"I I`o Airiest gal./inin.with stem set at fl.for hrs. Q Artesian flow g.p.m. Date 5/18/1 l . CI) Temperature of water Was a chemical analysis made? ❑ [l No Start Date 5/I4/11 Completed Date -C t ~ 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 are true to my best knowledge and belief. EDrillerL Engineer El Trainee Name(P t) Matt enningse Drilling Company Davis Drilling Driller/Engineer/Trainee Signature' Address 340.NE.Davis Farm Rd. Driller or trainee License No. 3077 , WA , 98528 City,State,Zip Belfair I IF TRAINEE:Driller's License No: Contractor's Driller's Signature: Registration No. DAVISDI I I O0A Date May 2011 ECY 050-1-20(Rev 06/08)If you need this document in an alienate format,please call the Water Resources Program at 360-407-6600. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.