HomeMy WebLinkAboutWAI2025-00052 - WAI Health Waiver - 7/14/2025 0 i ft",`".x MASON COUNTY
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G , l ) COMMUNITY SERVICES
l*%s 4'Y Building,Planning,Environmental Health,Community Health
VpJ•(LC{�a1
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •:• Belfair: (360) 275-4467 ext 400 Elma: (360) 482-5269 ext 400
FAX (360) 427-7787
Application for Waiver/Appeal SV
‘SI
Amount Paid: apo r 4iar3Receipt Number: o�95 - 00 -
Instructions (,U►Ca -0006�
1. Complete Parts 1 and 2. No determination can be made until these parts are full.By:u• - ed.
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 62 WEST LLC Telephone 360-426-4221
Mailing Address of Applicant 16110 CASCADOAM WAU
City LYNNWOO State WA _ Zip 98087
12-digit Tax Parcel No. 5 2 0 0 8 -- 5 1 -- 0 0 0 1 0
Site Address 62 WEST LAKE NAHWATZEL RD
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
O Building Permit Review Policies 0 Group B Water System Regulations
13:3 Location. WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
O Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
REDUCE HORIZONTAL DISTANCE BETWEEN DRAINFIELD AND AN EXEMPT WELL TO 75—ff'
1
Applicant Signature:C (4) 4,1, Cam} Date: 7 j 1 y,ZdZJ'
J:TH Fonns\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 1 of 2
ommisiimminiv
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal v 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)
WAC246-272-021OABLE IV
3. Nature of Appeal:
REDUCE HORIZONTAL DISTANCE BETWEEN DRAINFIELD AND AN EXEMPT WELL TO 75'- rS"
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board (DI At1/4 17C
M*ey OR Environmental Health Manager
5. Mitigating Factors: ( e
DRAINFIELD MEETS TREATMENT LEVEL B AND BL3
FOUR VICINITY WELL LOGS ATTACHED SHOWING AQUATARDS.(APPLICANT WELL LOG WAS NOT ON FILE)
SEWAGE WILL BE FLOWING AWAY FROM THE WELL
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:
PART 4: Determin tion of the Hearing Official
0S--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:
072-0
Hearing Official Signature: Date: ZJ
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2of2
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with J1 OOP... 2, G Sian Card No �� `�
File Orrpmal and F-rSIok,c ;PY WATER weLL REPORT
De Dartment of ECOlogy • ;3
Se:cnd Copy-Owner s Cn y STATE OF WASHINQTON
S t,.,d Copy -Dn•.er s:Luc, STATE Right Permit No _--
`' j . _1�� T U� _ I.1 k�Le�w v tit
O (1) OWNER: Name G r:f_ o AOdresT -"'r
CL
W (2) LOCATION OF WELL: county /el 4 S 4. ".+ -RAU 1r u s.cl.--T—N.R W
SA
cc
(ga) STREET AODDRESS OF WELL(or nearest.screen)
Irrigation
W (3) PROPOSED USE: .e D D.oegation Industrial C.: Municipal C (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
Water Test Well r Other G formetlon: Dimwits, by oobr, character. size of material and structure, and show
N thick...of aquifers and the kind and nature of the material in each stratum penetrated.
Owner's number of well with at least one entry for•ach change of rnlormation
(4) TYPE OF WORK: (it rrnrs than one) .._ •
--------- - -- MATERIAL • FROM TO
= Abanaoned Now well r/"Method' Dug Bored U
O Deepened Cable.----_' Driven 7 -!f,
Reconditioned Rotary Jetted 7 _ _ ___3 . 3 c,
_inches. a`!R
3c• ys'
O (5? DIMENSIONS: Diameter of veer - �_---
; ^ R ti e i� la y 6.c - _.-_4 -.. 8 -
E C^lied �.7 feet Depth otcomple!edwell._� _q� —n _ Ce M __.6 ]��� .PC- fI Q
(6) CONSTRUCTION DETAILS: �� t�_--� C_. _- Ica /O_�i.-
wCasing Installed: Oiam.from _ft.to tt. —5�'� SA-Af _ l s7 -
_ r• 1 af'�.2 ti!
= w•te.a .� �• . Oiam.from f /� N.to ? L n. /� •L'_ 4
a) Liner Threaded a�d i ' Diam.from h.to ft. SAL A/ G!C _-_ S
•I . Perforations: Yea ] NoZ el - - Q—
L Type of perforator...I (''tJ S14 C40411 ._
O SIZE of perforations _.. —in.by—_ _ in. -.-- ---._i.1l---_
C _ perforations from_ ft.to_. ft. _ -
CO
perforations from_. -..--N.to ft. ._. .. I -
,I -- __. ��yyperforations from_ - ft.to-_ H. _ - --"'
CI Screens: Yee�_.1 Nr� - - - .. .. -
_ - -t-
O Manufacturer's Name- -_ ... - __ _- - I
-C Type--_._ ._ Model No -.. 1
Jed __ ...-
Diem- ..Slot size— from.__ tt.to - -
iikii Diam. -.-Slot site. from tr.to ft. —. -
C - - 1 ..
� Gravel packed: YnC N9KJ size of gravel -
L. ft.
L Gravel placed from ._ H.to
CO __ 4 R-
I -
Static***at Y.� No❑fowhaldepth? /2 , +
Material used In seal a., TQ All 1- de
—
0 Did any strata contain unussble water! Ye.❑ Nod �—-
Z Type of rested- Depth al slrst• .--
tA Method of sealing strata off - - —
O (7) PUMP: M umucturer's Nam.
Type: -N•'
land-arAaoetdevallon
I) (8) WATER LEVELS: r .fro,,.mean .14 test N.
O StsNo la,« 9s ft.below top of well Data 4-1 i` 4 Z
OArteNen pressers es.per square Inch Oats
LU Aneslan water la controlled by Mee.eats+.elc-))
Work started 9` -i t Sd 1 — r l
ei-
O (9) WELL TESTS: Dna is a t water i.val is lowered below static level
ar Wes a puns test made?YesU No Li If yea,by whom? WELL CONSTRUCTOR CERTIFICATION:
Yield- ga{,rmm.waft_ ft.dre rdovm after hrs. I constructed and/or accept responsibility for construction o1 this well,
E - _"- •- •• -- - •• ••,. and its compliance with all Washington well construction standards.
Materials used and the information reported above are true to my best
i Recovery date(time taken as zero when pump turned oft)(water level measured
knowledge and belief,
ra from well top to water level) G�
IZ Tome WatrLevel Tow WetrLaw+ Taw Wolof level NAM
a) AM ,FIN OR COORPOfCA (TYPE OR PAW)
---- .- - - — Addres?a 0 X 413_ S7i e /4 Ai Gu A)
Date of test - ��i _ License No4,�4"T
{� (Signed)
Mailer test /`� gal.l min.with 3¢ N.d swdown after_.3 here. < LL MILLER) ��/�/
•
A{nest pal.l mstern hrs.
with set et ft.for • j Data 6` t
Artesian flow_ p.p.m. Date r--t
Temperature of water___- Wes a chemical analyse made? Year: Nor] (USE ADDITIONAL SHEETS IF NECESSARY)
ECY 050 1 20 00 erl -r520• 3
+.;
IL
a S-200 p-SI-oo 8
WATER WELL REPORT
036) b CURRENT
ECOLOGY Original&r copy-Ecology. 2Mcopy-owner. copy-driller
�[ Notice of Intent No.WE08434
InConstruction/Decommission("x"in circle)3e,T b�
❑X /
Construction ` Unique Ecology Well II)'Fag No. AAR620
❑ Decommission ORIGINAL INSTALLATION Water Right Permit No. EXEMPT WELL.
C Notice of Intent Number DAVID SOIKE
O Property Owner Name
PROPOSED USE: ❑x Domestic 0 Industrial ❑Mumapal
C ❑DeWater ❑Imgation ❑Test Well ❑Other - Well Street Address 140 LAKE NAHWATZEL DRIVE
rTYPE OF WORK:Owner's number of well(if more than one) City SHELTON County MASON
O ENew well ElReconditioned Method: ❑Dug ❑Bored ❑ Dnven
E ❑ Deepened ❑Cablc I)Rotary ❑ Jetted Location+L I/4-I/4 NW 1/4 Sec 8 Twn20N R 5W EWM ❑ Cheek
DIMENSIONS:Diameter of well 6 inches.drilled 134 ft. (s,t,r Still REQUIRED) WWM o One
O Depth of completed well 134 ft.
CCONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec
Casing ❑Y Welded 6 " Din n.from +2 ft.to 134 ft.
— Long Deg Long Min/Sec
43) Installed: ❑Liner installed " Dam.from ft to ft.
- ❑Threaded " Lharn.from ft.to ft. Tax Parcel No.(Required) 520085100008
Perforations: ❑Yes E No CONSTRUCTION OR DECOMMISSION PROCEDURE
0 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_fiom _ft to ft nature of the material in each stratum penetrated,with at least one entry for each change
C of mlonnation (USE ADDITIONAL SHEETS IF NECESSARY.)
A Saeans: ❑Yes Q No ❑K-Pac Location
Manufacturer's Name MATERIAL FROM 'IY)
etsType Model No. • BROWN SILTY CLAY WITH GRAVEL a 4
+r BROWN SILT BOUND SAND,GRAVEL 4 16
RIDiam Slot sill from ft to IL
0 Diam. Slot size from ft.to IL BROWN STICKY CLAY,FEW GRAVEL 16 23
- GRAY STICKY CLAY WITH LAYERS OF 23
QII Gravel/Fitter packed: ❑ Yes ❑>< No Size ofgravel/sand ____
t Materials placed from it.to tl. CEMENTED GRAVEL 31
r BROWN FINE SAND 31 34
Surface Seal: 0 yes ❑ No To what depth'? 20 ft.
+' vlater al used m seal BENTONITE CHIPS GRAY STICKY CLAY WITH(;RA VF.I. 34 38
C MEDIUM l'0 LARGE GRAVEL,BROWN 38
IRS Did any strata contain unusable water? ❑Yes i No SAND.TIGHT,COMPACT 54
EL,,, Type of water? Depth of strata MEDIUM TO LARGE GRAVEL,SAND WITH 54
CCII
Method of scaling strata off BROWN CLAY BINDER 93
PUMP:Manufacturer's Name GRAY MEDIUM TO LARGE GRAVEL,SAND, 193
Type: H.P TIGHT,COMPACT 121
0 WATER LEVELS: Land-surface elevation above mean sea level fl MULTI-COLORED GRAVEL,MEDIUM SAND, 121
Z Static level 92 ft.below top of well Date 6/24/08 WATER 134
y Artesian pressure lbs.per square inch Date
Slit
Artesian water is controlled by (cap,valve.etc.)
WELL TESTS: Drawdown is amount water level is lowered below static level
Was a pump test made? ❑ Yes ❑x No If yes,by wham? R--p try�y I, d 6r V-1
01 Yield: gal./min.with ft.drawdown after hrs. a p r,� L,,,i ur 191r�1f
O Yield, gal./min.with ft.drawdown after hrs.
O Yield. al./min with ft drawdown after hrs. AUG-0_
O Recoverydota(rime token as zero when pump turned of()(water level measured from well AUG� 2008
LLI top to water level)
g Time Water Level Tune Water level Tune Water Level \Vasnlng.t( n state _
O D=p!
i,,, n_,•t-n,-..on.t. r,f'F'r-n1nt.V
EDate of test I
Bailer Test gal./min with ft.drawdown after hrs. I
(5 Airiest 20 gal./min.with stein set at 120 n.for I hrs. I
CL
41,1 Artesian flow g.p.m. Date
CITemperature of water Was a chemical analysis made' ❑ Yes 0 No Start Date 6/I8/08 Completed Date 6/24/08
C WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
F"" construction standards.Materials used an the information reported above are true to my best knowledge and belief.
❑Driller❑EngineertTrainee Name )JOSH/ KOEPP Drilling Company ARCADIA DRILLING INC.
Driller/Engineer/Trainee Signature I Address PO BOX 1790
Driller or trainee License No. 2874
City,State.Zip SIIELTON . WA , 98584
I IF TRAINEE:Driller's Licens : Z.,..,,.•-eray Phythian #2053 Contractor's
I Driller's Signature: _- - Registration No. ARCADDI098K 1 Date 6/25/08
I
ECY 050-1-20(Rev 06/08)If you need this document in an alienate format.phase 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.
1 .
• .s_.2,0„..,,,, ,v,,,,
Start card No.
De Original and First
WATER WELL REPORT UNIQUE WELLLD.e « 1r
Department of Ef:ofogY
Second Copy-Owner's Copy STATE OF WASHINGTON
Third Copy-Drillers Copy Water lit Permft No.
O (1) OWNER: Name r �� Q�!/11 / r ..
Q • � Y� Trl�1
(2) LOCATION OF WELL: Comer lie4�I va Sec Y. •+.// N..R J
(2a) STREET ADDRESS OF WELL for nearer address;14)3)j L(t k f .1)1
j (3) PROPOSED USE: .DQ pre*.bC Industrial I I Municipal ID (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
Irrigation Formation,Describe by coon.character,sae of material and structure,and stow thickness of aquifers
(I
N t 11 DeWater Test Well [1 Other and the kind and nature of the material n each stratum penet•ated.with at lead ore entry for each
Owner's number o1 welt change of intormetion
r (4) TYPE OF WORK: (11 more than one) �
---.
MAT-FNUL _ FROM TO
C Abandoned 0 New well X Method. Dug Bored O - ,-
0 Deepened _ Cable it:, Driven❑ ),5 C' ,t r--ik 1 iL. C; a. 11 5) I
C Reconditioned Rotary:: Jetted 0 / -
o
7.1 (5) DIMENSIONS: Diameter of well 6 j X inches. Hord k-h -t cry,h_l +y (-/ / t
ca Drilled . _feet. Depth of completed well_ 11)6 h. rr/J r) N�1_1',4 1 �i 7elk1 r r 1 7_
10 P.l+ kA ,1/ ?lrv,,�l r- `
L (6) CONSTRUCTION DETAILS: aieLCe is y,j t So-Mr f).'r !.'r'1'.4.fti • /I
w Caging Installed: 6 - Diem.from 1- / ft-to /0C) fl. `� C G:c a
C a _ r ej Gc. ►s,.4. l ice L. at, tC �-
we+ded if,..
Diam.from _ ft.to h. f /
LJner Installedl
QJ Threaded ,, ' Diem.from ft.to _h.
s
Perforations: Yes El No R
o Type of perforator used —
-
.42 SIZE of perforations__ in.by in.
C perforations from .. h.to _ _- h.
R perforations from - h.to ft. -
,� perforaboru Iron' ft to ., h. - ..
•
CI -- Screens: Yes❑ No Al
t) Manufacturer's Name -
Type . ._Model No.
Diam. __Slot size__ _ttOm__. _tt.to_- __ h.
4.0
C Dram. Slot size from ft.to - h'
C ryt
Ldrawl packed: Yes CI No No Sae of gravel _— ,___ -- -
RI Gravel placed from .._ft.to ft. -
Surface sell: Yee x , No❑ To what depth"_ 1$`_ ft. '
1-- Material used in seal ,3CItif 1 f-C. __ -- - - - .- - --
0 Did any strata contain unusable water? Yes El NO p -- --
Z Type of water? -- --
Depth of strata - -' -
U) Method of sealing strata off _ _ - - — - --
° �u/ L�1d5 10 (7)(7) PUMP: Mar lecturer's Nance
>% Type• i�L 1/.1/nA2lY:irLlt tap
—
CD
(B) WATER LEVELS: Land3urface eleven on
° ��, above mean aea evel—_ ft.
Q Static level _ _ h.below top of well Date _ -
C.) Artesian pressu'e _. . _ Ilia.per square inch Date - - --
11J Artesian water is rortro'.led by — ^
(Cap.valve,etc.) Work Started `Jj 19 Competed f —.t9j_1_
sill, (9) WELL TESTS: Drawoown is amount water level is lowered below static level
C Was a pump test made" YeS C No C It yes.by whom? WELL CONSTRUCTOR CERTIFICATION:
W — Yield- gal'min w to h.dr zwddwn after__ hrs. I constructed and.or accept responsibility for construction of this well, and its
• compliance with all Washington well construction standards.Materials used and
L - the Information reported above are trueu to my best knowledge and belief.
0/ Recovery data(time taken as zero when pump turned off)(water level measured from well NAMES„1 A ootc.i t�, t_i e / CJl I.(iii ��
Q top to water level; tPesuav ii7kA on con ZTYPE enerrl
Time Water Level Time Water Level Time Water Level t . v n ^ yI )
CD — Address / �fCA '''CX ' 1 `. ' �/1st/" Ll `
1... — — (Signed) License No. C )-r. �4
Oat of test _
Contractor's
Bader kart f gal./min with __
, ft.drewdw on altar_ his._ V _ R�iB °n
Aihest _ gat(min.with stemset at - ft.for ..hrs. No.,�ALaf�e-4'Q'/I7C-A Date i' • / —.19Jj
Artesian Sow e.o.m. Oats (USE ADDITIONAL SHEETS IF NECESSARY)
Temperature of water Was a chemical analysis made? Yes IA No❑
ECL 050 1-20(2,931''t -taw- 0
s20vP•-sue aaUo y
N A T B R WELL REPORT start Card No. W119374
Unique Well :.D. k AFBI64
STATE OP WASHINGTON Water Right Permit No.
rill
G (1) OWNER: Name COLE, BOB Address 1662E 70TM PLACE N LYNNWOOD. WA 98037-
0. ___ ____ .... ____"_____
NW (2) LOCATION OP WELL' County MASON - SW 1/4 NE 1/4 Sec 8 T 20 N. R 5W WM
Ce (2e) STREET ADDRESS OP WELL (or nearest address) LAKE EAEWATLEL DRIVE, SHELTON
QO (3) PROPOSED USE: DOMESTIC (10) WELL LOG
(4)e TYPE•OP WORK: Owner's Number of well Formation: Describe by color, character, size of material
(If more than one) and structure, and show thickness of aquifers and the kind
NBW WELL Method: CABLE and nature of the material in each stratum penetrated, with
4.11
C: .yk -, at least one entry for each change in formation.
0 (5) DIMENSIONS: Diameter of we11 6 inches
Drilled 121 ft. Depth of completed well 121 ft. MATERIAL FROM. I TO
C ==_Y.====_"_____' .____..= CEMENTED GRAY CLAY 0 12
(61 CONSTRUCTION DETAILS: BROWN SAND WITH SOME GRAVEL 2 ' 16
03 03 Casing inetalled: 6 " Dia. from 1.5 ft. to 122 ft. GRAY CLAY AND cOEBLES 16 126
WELDED CASING Dia. from ft. to ft. BROWN CLAY WITH COBBLES 26 32
Dia. from. ft. to ft. BROWN SAND 32 143
LOOSE GRAY CLAY GRAVEL 43 58
5F Perforatior.c: NO CEMENTED GRAY CLAY COBBLES . 58 179
C Type of perforator ueed CEMENTED BROWN COBBLES 79 ) 88
CD SIZE of perforations in. by in. GRAY CLAY SAND a GRAVEL 188 96
C perforations from ft. to ft. BROWN LOOSE CONGLOMERATE 196 1113
4.0 perforations from ft. to ft. GRAY CLAY AND CEMENTED GRAVEL 1113 1116
5., perforations from ft. to ft. GRAVES. i WATER 116 121
13 Screens: YES
C Manufacturer's Name HOUSTON
R Type SLOTTED Model No. ( )
03 Diem. S slot size .030 from 116 ft. to 121 ft. .7 I'
03 Diem. slot size from ft. to ft.
0 '7
Gravel packed: NO Size of gravel
.0Gravel placed from ft. to ft. `
Surface seal: YES To what depth? 20 ft.
•I . Material used in seal BENTONITE •
Did any strata contain unusable water? No
03
L. Type of water? Depth of atrata ft. I
L. Method of sea-:ng strata off -
03
(7) PUMP: Manufacturer's Name
Type H.P.
Z (a)r -w cWATER LEVELS: Land-surface elevation
above mean sea level ... ft.
H St,,r.1c level 98 ft. below top of well Date 02/15/00 I
O Artesian Preceure lbs. per square inch Oat. I
0 Artesian water controlled by
Work started 02/00/00 Completed 02/15/00
O (9) WELL TESTS: Drewdown ie amount water level is lowered below WELL CONSTRUCTOR CERTIFICATION:
_ static level. I constructed and/or accept responsibility for con-
0 'a0 a pump teat made? NO If yes, by whom? etructlon of thin well, and its compliance with all
C) Yield: gal./min with ft. drawdown after hrs. Washington well construction standards. Materials coed
W and the information reported above are true to my bent
4— knowledge and belief.
0 Recovery data
i+ Time Water Level Time Water Level Time Water Level NAME ARCADIA DRILL/NO INC.
(Person, firm, or corporation) (Type or print)
CD
5- ADDRESS, SE 170/ l j jBVE/� /f
L Date of test / /
Q. Bailer test 20 gal/min. 2 ft. drawdown after 1 hrs. {SIGN8D1 ense No. 1992
Q Air test gal/min. w/ stem set at ft. for lire.
Q Artesian flow a.p.n. Date Contractor's
Temperature of water Was a chemical analysis made? NO Registration No. ARCADDIO96K1 Date C2/15/0000
=='---'_.._
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