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Home My WebLink AboutWAI2022-00062 - WAI General - 5/2/2022 _ , ,, , , Vvia a a ), .- --. doaC.s, y`: �c7 MASON COUNTY 3. irl COMMUNITY SERVICES ?`„ .4Y_. Building,Planning,Environmental Health,Community Health 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 Amount Paid: 1 tO . 41. Receipt Number: iais, ill 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 Identification Name of Applicant RAY C/O B-LINE CONST. INC. Telephone 360-426-4221 Mailing Address of Applicant 2971 E PHILLIPS LAKE RD. City SHELTON State WA Zip 98584 12-digit Tax Parcel No. 2 2 1 0 5 -- 5 1 -- 0 0 0 7 4 Site Address 3240 E MASON LAKE DRIVE WEST, GRAPEVIEW, WA, 98546 Subdivision Name and Lot Maddings Sunnyshore Add#3 Tr. 74 PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) O Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies 0 Group B Water System Regulations IA 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.): Applicant wishes to place an onsite septic disposal field 75'from private wells and 90'from surface water. Mitigation will include: 1) pretreatment system meeting Treatment Level B without add-on disinfection. 2) Use of pressure distribution while maintaining 36"vertical separation. 3) Ongoing O&M - ) Site low in hydrogeologic susceptibility to contamination -i.e. evidence of aquatards in area well logs (attached). 5) Disposal component downslope from wells. Applicant Signature. Cl�!►, •_ . .l, ',\ ..,1 Date: ®ti_` Z'C- r J:\EH Forms\Waiver-Appeal Mason.County Local Revised 1/20/2017 Page 1 of 2 • PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) t_Appeal Apl7Vaiver i None required Class A Class B i Class C LOC - 2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/ Standard revision) 7Lt .2.121C' — c2to "re....We TV 3. Nature of Appeal: R j r.C� d'r;d P44 Itr,» pitavAli L P at 1 Cl wa.i ra reel 4 "Ar? 1 eck ,r cIrrl4w4 .�•... sh.ar.e trove 4, Jn.*, 6' 1 ./v `t& . 4, Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board 44 Environmental Health Manager 5. Mitigating Factors: Lve/I IS /-.$0 oy,cad,eN pl- O't S'lle ryi-le.14 / f p.e-elerah J 40 3 `+ u8 ` wr e/ Ow an i s rd aI /3 It *4 ( L/� ••.-r �e 1.4..tsI La-e j a r„r,+re 4i hats b-eey Aid 1,1. of btu a viaA ed rmai e 1,►c* 'Ls (r 4'elf> 19b teM.1 `„e.ti l•y$ S3+.w atyJ.4is. r,1- (0,,, i Ad Aje>i rao get,Iic t erreerliji F A e.Ad?✓..fava4.r 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: RcrtrvArf4VY\ Date: 5 7 15/Z;Z-- 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: f 'L Z2, .1:\.F..Fi Forms\Waiver-Appeal Mason County.Local Revised 1.120/2017 Page 2of2 File Original and First Copy with WATER WELL REPORT Start Card No. W 18648 -_ Department Hof Ecology Second copy-owner's Copy STATE OF WASHINGTON Third Copy-Drifter's Copy Water Right Permit No.—_- - i 0) OWNER: Name Linda Reid &Carol Robinson Address 34Q8 NO, 37TH Tacoma, Wa. 98407 Q _Mason elk ENv 5 21 2E 41 (2) LOCATION OF WELL: County - sec T. N.,Ft W.M. et (2a) STREET ADDDRESS OF WELL(or nearest address) 3900 Mason LaKe Dr. W. Grapeview, Wa. 98546 0 (3) PROPOSED USE: IX1 Domestic Industrial I l Municipal I 1 (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION Li Irrigation ., i I 1 DeWater Test Well D Other ❑ Formation: Describe by color, character, size of material and structure, and show U) uW l 30 rl[ •- thickness of aquifers and the kind and nature of the materiel in each stratum penetrated, •� (4) TYPE OF WORK: awner's number ell u ft C7 with al least one entry for each change of information. _ (if more than one) `--_. all - ..-:-- e of in r -- -- - ----- r MATERIAL FROM i TO C Abandoned I : New well X Method: Dug L Bored C7 ___--_ -__.-_. . .__ I Deepened I 1 r)Ei. Cable IA . Driven El Q Reconditioned 1.1try 7i i••olP 1 t ed Li BRN S-G TOPSOIL LARGE ROCK 0 3 C pAsj)� � 6 iJ BRN S-G HARDPANTCOMPACT 73 Q {5) DIMENSIONS: Diameter of well inches. W-B COARSE SAND-GRAVEL 74 _ 80 ++ Drilled__S 0 leaf. Depth of completed wall 8 0+ tl CO BRN S-G HARDPAN 1 80 l -- L (6) CONSTRUCTION DETAILS: • 1i0 Casing Installed: 6 ' Dlam.from 0 _—ft.to_ 80 ft. I C Welded I Diem from ft. ft. Liner instaltod; : J- - _ Q Threaded i..i __. '. Dlarn_from ft.to ft. - ryy� Perforations: YesD NoL` I- L. Type of perforator used O SIZE of perforations_-._..-__ ._ in.by is ( .Z.4, 47--(2-.1.X.-- .0 ___ -..-- perforations from_ _ft.to_ ft. r3 __________ perforations from_--_ _ft.to_ ft. _.,_ _ _ I - - perforations from- ft.to tt. _ � Screens: Yes I.r�� No p� a Houston Flow -- c Menulaclarees0.1 taln.--I-eSS •C Type.-- Model No _ --• 4-1 .w 2 Diem.. Slot size 6 n -from_.�1 ft.to 80 N. -�- .N Diem.-._ __Slot size -from-._ ft.to ft. C z It Gravel packed: Yeses NoI Size of Crave' - D i I li— Gravel placed from tt.to ft. ( r _ Surface seal: YosL4 NO L_- To whet depth? 1 8 ft. - . ....A.n -- El l.- Material used in seal—__Bent Cal lte___._ - A Did any strafe conteinunusablewaler? Yes IA NoU Z _._-Depth of strata --- .. _- _-._-_- .__._.._.. Type of water?-. -- — U) Method of sealing strafe off . ---. - — 41 Q (7) PUMP: Manufacturer's Name. - .. --- -- 13 - Type:- H.P. .- "_ .- _--._._ - 1 (8} WATER LEVELS' Land-surface elevation Cr) above mean sea'oval ft. Q Static level_...3 6 ff.below top of well Date 4-2 9-9 4 VArtesian pressure __ _lbs.per square inch Dale_... _.__. . ..- - ...... - .- -- UJ Artesian water is controlled by (Cep.valve,etc..i- ------ - Work started-_._..__ _ - —,19. Completed .__.__-. __,19 0 (9) WELL TESTS: Drawdown is amount� water level is lowered below static level �r Was a pump test made?Year Nof.•J Y If yes,by whom? --- - WELL CONSTRUCTOR CERTIFICATION: C Yield: ._ _gal./min.with_.... _ft.drawdown alter hrs. C) - _._ I constructed and/or accept responsibility for construction of this well, E ,• and its compliance with all Washington well construction standards. Materials used and the information reported above are true to my best L Recovery data(time taken as zero when pump turned off)(water level measured knowledge and belief. Q. from well top to water level) al Time Water Level Time Water Level Time Water Level NAME HOLLAND PUMP CO. INC. ... , , , _._._ _-_ -.T---.-. ,------ -- __, _-,_- - (PERSON,FIRM,OR CORPORATION) (TYPE OR PRINT) P.O. BOX 581 , WAUNA, WASH. 98395 Z Address-. - - --- --- -- Date of lest . -- - C (Signed) .cle.¢'e__t ...K -- ____License No. 459,5 ..- Railer test __6_0 gal.I min.with-_.-...-0-_ft.drawdown after 6 hrs. (WELL DRILLER) Contractor's Airtesl ..... ..... gal r min.with stern set at__...--ft.for_ hrs. Registration / Artesian flow _. __ m. Date. _- No.HOLLAL*.2_1_0-Q-L-- Dale.---_... . �- - , 1997' Temperature of water -___.. Was a chemical analysis made? Yes Ll No! I (USE ADDITIONAL SHEETS IF NECESSARY) elk ECY050.1.?0 I,ii-ar) -i 329 '.'n 110 CERTIFIED MAIL@ RECEIPT ro ^ ' _u Domestic Mail Only,` ,. ru For n��vmm�� ^m*w��=��m�m IUNIu�� Extr Gro��/N�� 9��4@ �� H � B �� 02�~��K N�� -o n�v u�� o' u m� n *�. �� o �� ox °�m�� « ~��x��' .�x~«�oro°_m�° rncemdmm/m" .-u * $3.75 -''~-' ``� 0388 SHELTON .o 05 210 MARK [ REED WAY UNIT MAIN [IRuneephaop ----'-'1 ` SH[LT0N' HA 98584-8980 Cz On��n�**w�� * �� (8U8>275'8777 ^~ Oo�m�mm/n°m*��'�� * / o � `---.^.- -� '' __---_-'-� Delivery +T11 "t �� . /5/U5/2O22 U4'38 PN cz Omm»��n�m� ^ $*mxvw"��m"mw�v*��^ �� ruduot 0ty Unit Pri�o -11 El p�mn $1,36 Price _n $ ` ' |��*� ' ,� wm rwmn mmpmo `~ 2022 irot'Clanu Nai)@ 1 $1.36 $ ^ Envelope �,� ow' WA 90546 cz ��`"�~ Weight: U |b 1.40 m p 50A) Lr-, P�, Est\mated Deli ery Date . ' Sot 05/07/2022 V. Certified Ma| |@ $3.75 PS Form mDO,April mx,mp 71530 02-COD-9047 See Reverse for Instructions Tracking #� 70191640000066363268 otal $5.11 irand Total $5.11 lebit Card Cord Remitted $5.11 Card Name: VISA Account N: XXXXXXXXXXXX4223 Approval #: 478020 Transaction #: 852 Receipt #: 030538 Debit Card Purchase: $5.11 AID: N0800008900840 Chip AL: US DEBIT ' PIN: Verified ----'-' -- -- ' - -- - Every hnuuoho\d in the U.S. is now eligible to receive a ooumnd yet of 4 free toot kits. _ Go to www.uovidtno1s.gov Text your 'tracking nmnbur to 28777 (2USPS) 'to get the latest -status. Standard Mauna0p and Data rates may apply. You may also vioit wWuypsXom USPS Tracking or ca)\ 1-000'222-1811. Preview Your Mail Track yOU" Packages Sign up for FREE 0 rltp*://|rformoUUo)1 very.uxps.^mn All sales final on Stamps and pootage. Refunds for guaranteed services only. Thank You fOl- Your business. To|| uy aboutexperience. 0w to: htt a)�x»*r�nnr� �om/Puo or scan this ovdo with yuur mobile dov\cw' .9 a. ` ' �m or call 1-800-410-7420 i JFN: 547742-0300 B-Line Construction, Inc. tpt *=0B-LIii NE- CONSIOCiION t EXCAVATION 02 May 2022 Randy & Bonnie Lindblad 3250 E Mason Lake Drive West Grapeview, WA 98546 Re: Septic System Placement for 3240 E Mason Lake Dr. West Mr. & Ms. Lindblad, I am writing you on behalf of Mr. & Ms. Ray who own the lot located at 3240 E Mason Lk. Dr. West. I am a Washington State licensed septic system designer working for B-Line Construction. I have recently submitted a septic system design to Mason County Health concerning the Ray property.The only adequate area to install a septic drainfield is located approximately 75' away from your existing well. Normally a well setback of 100' is required, but the State and County regularly approve setbacks from drainfields to wells as close as 50' if certain mitigation measures are met. State/County requirement to meet a reduced setback to 75' is either: 1. evidence that a restrictive layer exists below the ground surface that would stop effluent from penetrating down to the depth of your well intake, 2. or evidence that the ground slope is AWAY from your well so subsurface effluent will be moving away from your well location 3. or a drainfield design that ensures enhanced treatment in addition to normally required vertical separation requirements. (See attached WAC requirements) Our proposal for this drainfield repair meet ALL 3 of the above conditions: • Area well logs show there are multiple subsurface impermeable layers preventing surface pollution from moving down to the depth wells are intaking water • The location of your well is about 3-4' higher than the proposed drainfield installation. This means water in the area of the drainfield cannot flow uphill toward the area of the well, AND • The proposed drainfield is pretreated with a Nuwater BNR-500 that is State approved to meet Treatment Level B without add-on disinfection (i.e. removes over 99.9% of wastewater pollutants BEFORE effluent enters the drainfield).. 2971 E Phillips Lake Rd., Shelton, WA 98584 360.426.4221 (office) 360.426.0509 (fax) b-lineconst(a,msn.com 41 B-Line Construction Inc. - -- = '. _0,1.,TI ,F%CF,,,,,, As part of the county's approval process, we are obligated to notify you of the proposed development. We can assure you that the system being placed on the 3240 E Mason Lk. Dr. West property will not adversely affect your water quality or property. If you have any questions regarding this development, please feel free to reach out to B-Line Construction or Mason County Health. Sincerlyt- - _� e, ,, r_ '1 `.: ::' 0144144( Z 1- 1( Toby Syrett 'r22 Licensed Onsite Wastewater Treatment System Designer#5100299 1 i 1 ( I I i 1 i i 1 2971 E Phillips Lake Rd., Shelton,WA 98584 360.426.4221 (office) 360.426.0509 (fax) b-lineconst(c4msn.com l L c. " ' WATER WELL REPORT CtMO Original&1"copy—Ecology,2nd copy—owner,3rd copy—driller CURRENT DEPARTMENT OF Notice of Intent No. WE08598 ECOLOGY Construction/Decommission ("x"in circle) aJs,a. w.,A,"Ri"" ® Construction ?, ici Unique Ecology Well ID Tag No. BAR637 In• ❑ Decommission ORIGINAL INSTALLATION CVJ Water Right Permit No. EXEMPT WELL Notice of Intent Number Property Owner Name GREGORY RICHARDS .-1 PROPOSED USE: tEl Domestic 0 industrial 0 Municipal C 0 DeWater ❑ Irrigation 0 Test Well 0 Other Well Street Address E MASON LAKE DR W O TYPE OF WORK: Owner's number of well(if more than one) City GRAPEVIEW County MASON O El New well ElReconditioned Melhad ❑ Dug ❑ Bored ❑ Dnven CI Deepened El Cable 0 Rotary 0 Jetted Location SE 1/4-l/4 NW I/4 Sec 5 Twn 21 N R 2W Ewm ❑ R3 DIMENSIONS: Diameter of well 6 inches,dnlled136 ft (s,t,r Still REQUIRED) Or E Depth of completed well 136 ft WWM VI CONSTRUCTION DETAILS y�F, Casing El Welded 6" Dam from +1 5 ft to 131 ft Lat/Long Lat Deg Lat Min/Sec C Installed: ❑ Liner installed " Dram from ft to ft Long Deg Long Min/Sec 0 Threaded " Diain From ft to ftal Tax Parcel No.(Required) 221055100039 Perforations: ❑ Yes El No -' Type of perforator used CONSTRUCTION OR DECOMMISSION PROCEDURE L Formation Describe by color,character,size of material and stnicture,and the kind and Q SIZE ofperfs 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 ...` Screens: El Yes ❑ No ® K-Pac Location 128 of information (USE ADDITIONAL SHEETS IF NECESSARY) C Manufacturer's Name JOHNSON MATERIAL FROM TO 011 Type SLOTTED Model No BROWN COMGLOMERATE 0 3 Dam 5 Slot size 18 from 131 ft to 136 ft BROWN HARDPAIX 3 18 cc Dam Slot size from ft to ft GREY HARD ION fr 18 24 a Gravel/Filter packed: 0 Yes 0 No Size of gravel/sand BROWN CONG(MOIST) 24 60 a Materials placed from ft to ft BROWN SILT BOUND 3/6 60 4-+ Surface Seal: El Yes 0 No To what depth.' 25 ft SEAPAGE 86 9-as• Material used in seal BENTONITE CHIPS GRAY SILT LAYER 86 101 C Did any strata contain unusable water9 CI Yes ID NoVII LITE BROWN SILT BOUND 101 L- Type of water9 Depth of strata SAND AND GRAVEL(SOUP) 127 s... SAND AND GRAVEL W/B 127 136 Ca Method of sealing strata off PUMP: Manufacturer's Name I ' Type H P 0 WATER LEVELS: Land-surface elevation above mean sea level ft Static level 39 ft below top of well Date 09/11/2008 all Artesian pressure lbs per square inch Date _ 1 ,� Artesian water is controlled by (cap,valve,etc) _ • WELL TESTS: Drawdown is amount water level is lowered below static level ca Was a pump test made.' ❑ Yes ® No If yes,by whom° (2"\W O0 Yield gal/min with_ft drawdown after hrs Yield gal/min with ft drawdown after hrs W Yield gal/min with ft drawdown after hrs y_, Recovery data(time taken as zero when pump turned oll)(water level measured front well 11' O top to water level.) �' �lE y_ Tune Water Level Time Water Level Tune Water Level — �q`I p� LVO8 qR g C NOV V 5 a) E Washington State Date of test AI 0. Bailer test 10 gal hnm with 55 ft drawdown after 3 hrs Departtrre„t of Eeulogy Q Airtest gal hmn with stem set at ft for hrs Artesian flow );pin Date Start Date 08/26/2008 Completed Date 09/11/2008 Temperature of water Was a chemical analysis made.' 0 Yes is No 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. ®Driller❑Engineer 0 Trainee Name(tirini) M K LSO Drilling Company ARCADIA DRILLING INC ^Driller/Engineer/i Driller/Engineer/Trainee Signature G'c j ��✓Gf7 �� Address PO BOX 1790 Driller or trainee License No. 1992 City,State,Zip SHELTON , WA, 98584 IF TRAINEE.Driller's License No' Contractor's Driller's Signature Registration No ARCADDiO98K1 Date 09/15/2008 ECY 050-1-20(Rev 06/013) If you need this document in an alternate 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. 0 aa) '�" '"-�''- WATER WELL REPORT CURRENT CC -. Original&1°copy-Ecology,2nd copy-owner,3Fd copy-driller Notice of Intent No.WE 09682 DEPARTMENT OF a 1 ECOLOGY Construction/Decommission ("x"in circle) Unique Ecology Well ID Tag No.BBE 049 State el Washington ® Construction Water Right Permit No. y ❑ Decommission ORIGINAL INSTALLATION Property Owner Name Steve Lewis Notice of Intent Number • PROPOSED USE: El Domestic 0 industrial 0 Municipal Well Street Address 3360 E Mason Lake Drive West O 0 DeWater 0 irrigation 0 Test Well 0 Other City Grapeview County Mason C TYPE OF WORK: Owner's number of well(if more than one) O El New well ❑ Reconditioned Method:0 Dug ❑ Bored 0 Driven Location SW 1/4-1/4 SW l/4 Sec 5 Twn 21 N R 2W Fmk' 0 4:"r 0 Deepened El Cable 0 Rotary 0 Jetted (S,t,•r Still REQUIRED) Or 011 DIMENSIONS: Diameter of well 6 inches,drilled163 ft. WWM El E Depth of completed well 16311. • CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec 4"' Casing El Welded 6" Diam.from +1 ft.to 155 ft. Long Deg Long Min/Sec - Installed: 0 Liner installed " Diam.front ft.to ft. Tax Parcel No.(Required)221055100062 C ❑ Threaded " Diam.From ft.to ft. C Perforations: DI Yes 0No CONSTRUCTION OR DECOMMISSION PROCEDURE L Type of perforator used Formation:Describe by color,character,size of material and structure,and the kind and O SIZE of perfs_in.by in.and no.of perfs_from R.to ft. nature of the material in each stratum penetrated,with at least one entry for each change ❑ No ❑ K-Pac Screens: ® Yes Location 146 -_ _- -._ of-information. (USE ADDITIONAL SHEETS-IF NECESSP.RY-)- - C MATERIAL FROM TO (Z Manufacturer's Name Johnson Dark brown topsoil 0 1 (' Type Slotted Stainless Model No. Brown conglomerate 1 11 Diam.5Slot size.012 from 153 ft.to 158 fl. Gray Hardpan 11 22 O Diam.5Slot size.010 front 158 ft.to 163 IL. Siltbound sand and gravel 22 31 a) Gravel/Filter packed: 0 Yes 0 No Size of gravel/sand Redish brown silty 31 ,� Materials placed from ft.to ft. 44 r sand and gravel >1 Surface Seal: El Yes 0 No To what depth?31 ft. Brown hardpan 44 62 vir"' Material used in seal Bentonite Chips • Grown silty sand and gravel 62 84 03 Did any strata contain unusable water? ❑ Yes El No Light brown hardpan 84 101 i Type of water? • Depth of strata Brown conglomerate 101 159 7 Method of sealing strata off Medium sand with trace 159 } of gravel,water bearing 163 PUMP: Manufacturer's Name 0 Type: H.P. Z WATER LEVELS: Land-surface elevation above mean sea level ft. y Static level 47ft.below top of well Date 11/17/2011 O Artesian pressure lbs.per square inch Date L�E e"0 Artesian water is controlled by (cap,valve,etc.) cz-e- -i- -t • WELL TESTS: Drawdown is amount water level is lowered below static level - O Was a pump test made? 0 Yes El No If yes,by whom? • Yield: gal./min.with ft.drawdown after his. R 0 Yield: gal./min.with ft.drawdown after hrs. �E LU Yield: gal./min.with ft.drawdown after hrs. 4-. Recovery data(lisle taken as zero when pump turned off)(water level measured front DEC 1 C °V 1 1 O well top to water level) `n' r '~• Time Water Level Time Water Level Time Water Leveliv yY� �l.i-.ate LJr�I t� r + of ErD1q '•rncnz 5Y (S WRO) E — L• Date of test • CL Bailer test 20 gal./min.with loft.drawdown after 21trs. (i.) Cl Airtest gal./min.with stem set at ft.For hrs. a Artesian flow g.p.at. Date Start Date 10/26/2011 Completed Date 11/17/2011 I- Temperature of water Was a chemical analysis made? ❑ Yes 0 No WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction ot'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. ®Driller C]Engineer❑Trainee Name(Print)Mark Nelson /' Drilling Company Arcadia Drilling Inc. Driller/Engineer/Trainee Signature /j?/��.` ,/��r —�-- Address Po Box 1790 Driller or trainee License No. 1992 City,State,Zip Shelton , Wa, 98584 IF TRAINEE:Driller's License No: Contractor's Driller's Signature: Registration No. ARCADDIO98K1 Date 11/22/2011 ECY 050-1-20(Rev 02/10) / von need this document in an alternate format,please call the Water Resources Program al 36(1-407-6872. • Persons with hearing loss can call 711 Jar Washington Relay Service. Persons with a speech disability can call 877-833-6341.