HomeMy WebLinkAboutWAI2026-00066-APPLICATION FOR WAIVER/APPEAL - WAI Health Waiver - 7/31/2026 415 N.6'"STREET, SHELTON WA 98584
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Public Health & Human rvices "(
Application catFion for Waiver or Appeal
Amount Paid. _p `L Receipt Number. & - 0
WAI dS4 -00C
Please t all approvedO it Waivers have the me expiration date as their 055 Permits.
Instructions:
1. Complete Parts land 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 Lloyd Zook Telephone 360 791-3724
Mailing Address 1310 W GOLDEN PHEASANT RD
City SHELTON State WA Zip 98584
Parcel No. 3 1 9 0 6 -- 5 0 _ 0 0 0 3 0
Site Address 1310 W GOLDEN PHEASANT RD,
SOMERS HIGHWAY TRACTS (UNRECORDED) TRS 14A-16A
Subdivision Name and Lot
PART 2: Nature of WaiverlAppeal
❑ Onsite: Class A Waiver ❑ Food Sanitation Requirements
❑ Onsite: Class B Waiver ❑ Group B Water System Regulations
❑ Onsite. Class C Waiver ❑ Water Adequacy Requirements
1 Onsite: Location, WAC246-272A-0210 ❑ Building Permit. EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- ❑ Appeal: Enforcement Time'ine=_
0240 ❑ Appeal. Departmental Determinations
❑ Onsite Contractor Certification ❑ Other
Requirements
Description of Waiver/Appeal(include justification, additional material may be attached.).
Reduce Horizontal separation to Winter Water Drainage Ditch (surface Water) from
100' to 75' with TLB & BL2.
Applicant Signature: Date: 7' 3l _
Rcciscd 01..032026
This form may be scanned and available for public view on the Mason County Web site.
Pape I or 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
❑Appeal yp Waiver ❑ Class A ❑Class B- ❑Class C Ls Local
tC State Waiver Criteria
Number of Bedropms: 3 Nitrogen Treatment: t9Yes ❑ No
Soil Type: Minimum Lot Size: sq.ft.
Water Source:❑Public L7Private This Lot Size: sq.ft.
Is This Lot Eligible for State Waivers: 'Yes ❑ No ❑ N/A
Hearing Official:
Environmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/Stand rd/ Determination (include date of determination or latest
Code/Standard revision): *hlc2'{&'2?ZN-U710
3. Nature of Appeal:
gcdv , mom bm*z /of ce*@-at4n 6Gf-eCn ,jmr fl&W 4�1a'
trnW jtn, 1i o fit 1 no/- ftff
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.
Health Official Signature: Date.
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2
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Start Card No. 057519
Y A I E N Y E L L . E P 0 R T., Water Right Psnit No.
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9 (U TYPE OF YORKs . (If more then one)
tested, with
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NEW HELL ..............
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(5) DIMENSIONS It...v MATERIAL 0 7
titled 79 ft. Depth of cOryleted well 79 f.• . BROWN SAND & GRAVEL 7 21
(6) c sT .••••.x..a=...=:a....... ...:...v=.=.r_== - BROWN CLAY 21 34
(6) CCTION DETAILS: ft. to 79 ft. 6RWN CLAY 5 GRAVEL 34 50
Cainet1K lestaI led: I. Din. from 41 ft. to ft. BROWN SAND CLAY 5 GRAVEL 5p 52
6 ^ Dos. fromft SAND GUY CLAY 52 55
WELDED 01.. from it. to .. ...... SLACK SAND 5 GRAVEL CLAT 55 56
_........................ BLACK GRAVEL SAND 55 65
GUY CLAY 65 7B
Psrferatof p NO is 65
• Type of perforator used In• 17 in. GREEN CLAY GRAVEL
p SIZE of parfnatiw ft. to ft. WV CLAY
perforatioes frr fr
perfirsti ft. to ft.
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scream : YES HOUSTON
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Tips SLOTTED
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+ dot size ft. to
D Dir. ft.
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Site of Drava
Grasso packed: MO ft. SO ft.
gravel PIKed from ------------ ------
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es ---- ---- ---- --- ---- ------ - -- ---
Surface
motorist used
Old arr/ strafe contain ,,nrabla tra
Type of ester?
tithed of scal%ng strata off
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(5) WIER LEVELS: L rM' UI(iyl ...
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o ll DstC 07/10/92
0 Artesi Prntw't (b. per aqa loch Date C9glstd 07/10/92
) Artesia water controlled b/ York started 07/^10/92.
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Tilts:
011 CERTIFICATION+ 5N11ty ix earn
T (9) WELL Teas: static L (. wag^L 11etK iMl 1a Lowered NoteN NEu CDRStnxied nyor accept r.P ...
static level. atruetin at Chia sell, aed Ita Caarls. mater d*Lued
yp a pup test sods? N0 If Ys fi dr.wd0 1 after hr.. Y.shinStn wall canrtructln ttttdards•
3 Ti.ldt Ml.lNin with theIIMWIeiinf�Stl0nireported above w tru to w Dent
Recovery date Level MANE ARCADIA DRILLING INC.
Toes water Laesl Iles water LML Ties water (Persn, fire, or corporstin7 (Typ or print)
ADDRESS SE 7
•-i{icmm No. 0950
+ Date of test / / it. drawdon after Can. ISIGNEO)..
biter test 9.1101 ft. for 1 hr..
air test 10 pd/min. w wf/ atr set at 79 Data CntrKnr'. Data 07/10/92
chemical
analysis
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Im"r ture 01 water .......... ••• ••• .a
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