HomeMy WebLinkAboutWAI2025-00042 - WAI Health Waiver - 6/23/2025 vf.GA
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MASON COUNT
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(/' ° 4 ( _,OMMUNIT
Y SERVICES
Jilding,Planning,Environmental Health.Community Health
N 6'1 Street, Bldg 8, Shelton WA 98584,
:• Belfair: (360) 275-4467 ext 400 4• Elma: (360)482-5269 ext 400
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(1 FAX (360)427-7787
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\J \pplication for Waiver/Appeal [Of
Amount Paid: #3 0 C f UN 2 10Z5
Receipt Number: 107-5.-0 NO? RECE/vED
Instructions W/qT 2_ d 25- 0OD [ '�
1. Complete Parts 1 and 2. No determination clan 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 "aiIIi^ ly -
Name of Applicant L I CA-6\ PI '\ Telephone 3 LA.) - I (--i 3 7S
Mailing Address of Applicant 32--ib / Vz. `IAA 15 -t'Y/A1i Y\A 2-4 p
City J e.\-C \ I State,SIN fl Zip ! OS 22U
12-digit Tax Parcel No. ) 2 ) 0 9) -- . l -- 1 0 n J
r Site Address l 5 4 Cp J &17 < 1-'- ware v i e viu
it Gl 1 ` ) `--/
Subdivision Name and Lot
For wec zozr-0003I
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation 0 Food Sanitation Requirements
❑ Building Permit Review Policies - Group B Water System Regulations
❑ Location,WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.): .
okArtir l\o c\, w e<\\ .1/41t FO\-i— Sh 00J 5 2 . s;9 r ‘fi c_oof
confi0;,., c1rA13 Iw--S erg cA.by.Je 11't c ,J; f-etf,
Applicant Signature: ' 1--- \ r Date: La--2O -� ---
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Pace : of
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal i Waiver None required Class A i Class B i Class C
2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/
Standard revision)
3. Nature of Appeal:
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board 0 Environmental Health Manager
5. Mitigating Factors:
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: 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:
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:
Hearing Official Signature: Date:
J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
Mason County WA GIS Web Map
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MO Et ISLAND CREST RD ''
0)EI ISLAND CREST RD
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180 EIBUCKINGHAM LN
%all 220 ElBUCKINGHAM LN ' /
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MO E ISaNDYCREST RD
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6/3/2025, 9:29:57 AM 1:766
0 0.01 0.01 0.02 mi
Li] County Boundary I -, . , . ,l t ti . , t , 1
0 0.01 0.02 0.04 km
No Filled
° Site Address (Zoom in to 1:3,000)
Source.Esri.Mazer,Earthstar Geographies.and the GIS User Community
Tax Parcels (Zoom in to 1:30,000)
Mason County WA GIS Web Map Application
Mason County disclaims accuracy.reliability,or timeliness of website info,not liable for losses from reliance on it.httpsa,'www.masoncountywa.gov/disclaimer.php
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WATER WELL REPORT DEPAR'AlENT O' Notice of Intent No. WE58668
ECOLOGY
Unique Ecology Well ID Tag No. BQC 492
Type of Work: State of Washington
!i Construction Site Well Name(if more than one well):
^_.1 Decommission e=> Ohigina!installation NOI No. Water Right Permit/Certificate No.
Proposed lase: A Domestic :7 Industrial L. Municipal Property Owner Name Clad Allen
=Dcwatcrine D Irrigation Test Well =Other Well Street Address 161 E Island Crest Rd
Construction Type:
Method:
I New well IAlteration -Driven 0 Jetted !l Cable Tool City Grapeview County Meson
Deepening C Other C Dug 0 Air- 3 Mud-Rotary Tax Parcel No. 121087590040
Dimensions: Diameter of boring 6 in.,to 130 ft. Was a variance approved for this well? ❑Yes 0 No
Depth of completed well 130 ft.
If yes.what was the variance for?
Construction Details: Wall
Casing Liner Diameter From To Thickness Steel PVC Welded Thread
IN I 0 6 in. +1 120 1/4 in. r I 0 O 0 Location Isee instructions on page 2): 0 WWM or'0 EWM
O 1 ❑ in. — in. ❑ I 0 0 1 0 NE 1/4-'/4 of the NE '/.;Section 8 Township 21N Range 1W
O 1 0 in. — — in. IJ I ❑ C7 I ❑ 47.329285. 122.825276
O I 0 in. in. ❑ I 0 0 I 0 LatitudeIExample:47.1_3451
Longitude(Example:-I20.12345)
Perforations: C Yes No Type of perforator used Driller's Log/Construction or Decommission Procedure
No of pertiirations_ Size of perforations in.by in.
Perforated from ft.to ft below ground surface Formation:Describe by color,character.sire of material and structure.and the kind and
nature of the material in each layer penetrated,with at least one entry for each change of
Screen: .A Yes J No Ill K-Packer t> Depth 117 ft. information. Use additional sheets if necessary.
Manufacturer's Name Johnson Material From To
Type stainless Model No.
Diameter 5 in. Slot she 12 in.from 120 ft.to 130 ft Sandy brown topsoil 0 5
Diameter in. Slot size in.from ft.to ft. Clay bound brown sand 5 88
Blue clay 88 113
Sand Filter pack:7 Yes No Svc of pack matenal in Grey sand and some gravel with water 113 130
Materials placed from ft.to ft.
Surface Seal: ±i Yes 0 No To what depth? 18 ft.
Material used in seal bentonite
Did any strata contain unusable water? 0 Yes 0 No
Type of water? Depth of strata
Method of scaling strata off
Pump: Manufacturer's Name Arundfos Type: sub
H.P. 1.5 Pump intake depth:120 ft. Designed flow rate: 15 gpm
Water levels: Land-surface elevation above mean sea level ft.
Stick-up of top of well casing ft.above gmutai surface
Static water lei-el 22 ft.below top of well casing Date
Ancsian pressure lbs.per square inch Date
Artesian water is controlled by (cap.valve,etc.)
14en lests:
I Was a pumping test performed? CIT No a Yes b by whom?
Yield gpm with_ft.d-awdown after hrs.
Yield gpm w ith ft.draw down after hrs
Yield gpm with ft drawdown after hrs.
Recovery data Rime -lee,when pump is wined of-water level measured from well
top to water level)
Time water Level Time Water Level Time Water Level
Date of pumping test
Bailer test 15 gpm with 100 ft drawdown after 2 hrs.
Air test gpm with stem set at Il.tie hit } Date
Artesian flow gpm
Temperature of water "F was a chemical analysis made? I Yes I No Start Date 2-1-25 Completed Date 4-1-25
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 arc true to my best knowledge and belief.
C Driller I Trainee C PE-Print Name Mike Davis Drilling Company Davis Dolling
Signature Address 340 NE Davis Farm Rd
License No.0797 City.State.Zip Belfair,WA 98528
IF TRAINEE:Sponsors License No. Contractor's
Sponsor's Signature Registration No,DAVISDI1100A Date April 2025
EC'Y 050-1-20(Rev 08rl9)lwou need this document in an alternate format,please call the Water Resources Program at 36D-407-6872.
Persons with hearing loss can call 711 for llachington Relay Service.e. Persons with a speech disabiliy can call 877-833-6341.
MASON COUNTY N° 2 2 4
GENERAL SE"AICESPARTMENT
I a l 08 _ 15 . 9 00--10 ENVIRONMENTAL HEALTH SECTION
303 NORTH 4th STREET . SHELTON,WA 98584
PHONE (206)426.5561 7: f '
RECORD OF FINAL INSPECTION OF YOUR SEWAGE DISPOSAL SYSTEM 71S3 1.
OWNER c N oto ADDRESS �1 dCI 3 e_Se Q/ �(�
THIS RECORD IS NOT A GUARANTEE,OF PERFORMANCE. LEGAL t 0/S--
U�/
A SEPTIC SYSTEM IS NOT A MUNICIPAL SEWER. HOWEVER DESCRIPTION `f•F I L /� S G� 1 y
WATER WITH PRO ER IT AN GIVE MANYN EAS OF ROUEECE AND L FEEESERF t d' 6)J_ . T� g,F $71 ,
VICE. MANY PROBLEMS WITH SEPTIC TANKS ARE CAUSED SOIL 6 V L /6(?. [LC0
BY FLUSHING EXCESSIVE AMOUNTS OF PAPER, CLOTH COMMENTS (70-011
AND PLASTIC MATERIALS DOWN THE DRAIN, OR BY SITE FIELD X
LARGE AMOUNTS OF WATER FROM LEAKY FAUCETS OR NO. SIZE / �5 _,
FAULTY FIXTURES. DEPTH TO MONTH
THE SEPTIC TANK ITSELF SHOULD BE CLEANED EVERY WATER TABLE OF YEAR
TWO OR THREE YEARS DEPENDING ON THE HABITS OF THE INSTALLER () iza j
FAMILY, THE NUMBER OF FIXTURES IN THE HOUSE, AND `� " ����
THE AMOUNT THAT A GARBAGE DISPOSAL IS USED. CLEAN- SIZE
ING AT THE RIGHT TIME WILL AVOID THE RISK OF INJUR- SEPTIC TANK (S) �n0 G► Q�. ev L _ 2 � �
ING OR DESTROYING THE DRAINFIELD DUE TO SOLIDS DRAINFIELD ` FEET
CARRYING OVER INTO THE DRAINFIELD. CALL THE LENGTH r�js ct���
MASON COUNTY HEALTH DEPARTMENT FOR A LIST OF TRENCH AREA 3 SQ. FT.
'r
LICENSED SEPTIC TANK CLEANERS IN YOUR AREA. THE -
TILE CLEANER CAN SERVE YOU BEST IF YOU SHOW HIM THIS DEPTH I Z- I S ' 0 CORRUGATED RIGID l;; CEMENT
RECORD WHEN HE COMES. DEPTH
ROHEAVY TRUCKS OR EQUIPMENT SHOULD NEVER BE CU. K L
BE�a�� DEPTOTTH
CU. YDS. /�j PIPE {j / L DEPTH
DRIVEN OVER THE TANK OR DRAINFIELD. CONSULT THIS SPACE RESERVED FOR
RECORD IN CASE OF ANY BUILDINGS, DRIVEWAYS, REPLACEMENT DISTRIBUTION FIELD: CI .L' • SQ. FT.
SWIMMING POOLS, OR EXTENSIVE GRADING OR FILLING
44 NORTH
ARE LATER CONTEMPLATED. �' I z -•
SHRUBS OR TREES SHOULD NOT BE PLANTED CLOSE TO
THE SEPTIC TANK AS THEY WOULD INTERFERE WITH
CLEANING OF THE TANK. THEY CAN BE PLANTED IN THE
DRAINFIELD AREA PROVIDING WILLOWS ARE NOT USED.
THE YARD GRADE IN THE DISPOSAL AREA SHOULD BE
SUCH THAT SURFACE WATER IS NOT POCKETED ON THE
DRAINFIELD. ANY SETTLING OF THE GROUND OVER THE
TRENCHES SHOULD BE FILLED IN WITH SOIL. DO NOT EX 5 0
-
CESSIVELY WATER THE LAWN IN THE DRAINFIELD AREA. I S---
WATER EVAPORATION FROM THE DRAINFIELD IS ABOUT I j -
EQUAL TO ONE HALF INCH OF RAIN PER DAY. i
FOOTING DRAINAGE, DOWNSPOUTS AND WATER II IA" i L7i
SOFTENER RECHARGE WATER SHOULD NOT BE CON-
NECTED TO THE SEPTIC SYSTEM OR DISCHARGED INTO THE
DRAINFIELD AREA. b 11 )
THE TYPES OF BACTERIA NEEDED IN A SEPTIC TANK ARE 5 I
ALWAYS FOUND IN SEWAGE. THERE IS NO NEED TO ADD '
YEAST OR OTHER STARTERS TO A SYSTEM. THE USE OF RE- I z J 7
JUVENATORS OR CHEMICALS TO CLEAN A SEPTIC TANK I 1
HAVE NOT BEEN PROVEN TO BE BENEFICIAL AND MAY BE `
HARMFUL BY FLUSHING SOLIDS OUT OF THE TANK OR BY
CHANGING THE CHARACTERISTICS OF THE SOIL. THE k
NORMAL USE OF BOWL CLEANERS OR CLEANING COM- )
POUNDS WILL NOT KILL THE BACTERIAL ACTION OR SLOW _ SOUTH
DOWN THE OPERATION OF THE SEPTIC TANK. q -C6-C? •( -------..„..,.,,6t, (-- ...,, \ ,
Gai-\
THIS IS AN IMPORTANT_DOCUMENT n l D Ivy �, ! APPROVED BY
������ I MITH DEED OTHER Y ( 61 .49,,An2,
PrintergrAWINaRNIEnunty DMS DATE CERTIFIED BY
Apr I I t0 IV.ILA .tuywryi I wI a a.• --- --- — r-••
RECORD DRAWING (AASBUILT) Mason County Public Health
A Ssor's Parcel a 1 d e2 a l i�OO b 1-.___
Permit Number S o�0 1 r - d a 15 ' (Twelve-Dilgit Number)
Applicant's Name ,ch F'., Ph tL..14, 1 Subdivision (NarndDltrisiadSibcirli,ot)
Applicant Address '11.;/S a l'[nstallar.s Nrne .3rn4 , 6,11 4.nt..4
ere
op state,z .Ar.Lo eta n yA / e De.i Niche l'Aitr-'- VP,hi-
,
N/A Yes Prior to Centipletton
I. SEPTIC TANK
>5 it.From feundatice?...................._......... ......»........._.......... p ❑
>50 ft fiartn welts? .. .... ... . ........... .............._...._.._ p Or 0
>50 ft tatr ace wates'1 ..... ............... .,.............._............ .. O .i3 0
Building stubout to septic tank cleaning if not 1-2%? p ❑
Baffles intact and cle�4......... _......................_.__..._.... 0 0' ❑
Dividing wall intact?............ .. .. . ........_........_.»....»:.- Q is o
air. .. ....•............................_....... ❑ .e� 0
Screen baslr etlt cte one) .._.. ._--._ Q 0
Tank sine: 1)D gal: btamdacturec 07:Ld, .4.II64/Vie •
II. D-BOX ' Y
/
Leveled with water? ❑ Cl
Speed leveler used? —.- Vd 0 0
III. DRAINFIELD /
>10 ft fora foundation? 0 0 Rj
ft from
>5 property lines and easement lines? ❑ 0
> 100 ft from wells? 0 � 0
>100 ft from surface water? ... 0 ❑
>10 ft from potable water lines? 0g/ 0
Laterals level to±1 itch dt end caps present d'art looped?............. 0 !a 0
Graveness chambers utilized? 0 z 0
Gravel clean,properly sued,and proper deg ?.. • 0 O
PIsssURsSYs•rutis
Sand quality ASTM C-33? ..............._ -. 0 ❑ •
Head height uniform 24 incbes? Actual head height tl� ci Ae 0
Clean-out.and observation ports present? O :,,-, ❑
Mound: Side Slope 3:1? 00
Owner informed electrical carmections must be made by
owner or licensed electrician sad inspected by LW?_.........._ 0 V 0
IV. lUMP1PUMP R
Pump make Zs. : Pump model (a u 2 .511/7'7 a O
Chamber size a gal; Manufacture Pi.Z 5 p • ,o" 0 L
r
Height of pump offbottom of pump chamber y'' incites
Pump chamber draw-down A' t gallons per inch per minute 04 `" ,
capacityPump l.
t •, • - per minute
Pump Tm�er,Elapsed Titre lifklcr, . ,- •(Circle all CI Id tV
that apply). If .1ltsirun • ear- • CI- i
Riser installed for screen?................. ._......._............._......._ p p CO
Alarmimaalled?.. ....-.-.-.-_-..........,......................_..- p p
Printed From Mason County DMS '-
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