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HomeMy WebLinkAboutWAI2023-00023 - WAI Health Waiver - 3/17/2023 MAR 17 2023 N. 6th STREET,SHELTON WA 98584 / MASON COUNTY SHELTON: 360-427-9670,ext 400 I1111MITIF I COMMUNITY SERVICES BELFAIR: 360-275-4467, ext.400 Building,Planning,Environmental Health,Community Health ELMA:360-482-5269,ext.400 :• FAX:360-427-7798 Application for Waiver or Appeal^� ,l Amount Paid: 3E� `5 Receipt Number: c O? LL- kv WAI cpbcaS - O 3 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 Information Name of Applicant G2d af(& t- ci` K-K Telephone ad - Jo— J9 8 Mailing Address -70 Nts." V C'`v/e- City �� •( State 0U �i Zip I O Sc g Parcel No. 3 a S -- 9 0 U 2 0 Site Address 1J C P.c.< geA Subdivision Name and Lot PART 2: Nature of Waiver/Appeal Fr , IV Class B Reduce Vertical Separation ❑ Food Sanitation Requirements .., lj" ••la ❑ 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 ;r g L ❑ Mason County Onsite Standards 0 Departmental Determinations ❑ Contractor Certification Requirements 0 Other (Installer, Pumper, O&M Specialists) -J a Description of Waiver/Appeal (include justification, additional material may be attached.): i REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY b CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE Applicant Signature: /;f15 :.Ig _e/ir Date: Siii/Z023 Revised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 3 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver (if applicable) Appeal /Waiver - None required i : Class A /Class B 7 Class C 2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/ Standard revision): WAC246-272A-0230, TABLE VI 3. Nature of Appeal: RFDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL GRAVITY 4. Hearing Official: ❑ Board of Health 0 Health Officer O Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board 07 Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST (MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN Z([6SZ9 l on f(414 I17i) cvp ''3k 7 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. ".2---- Staff Signature: Date: - 5( 7( /7 Z3 PART 4: Determination of the Hearing Official a- 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: ❑ 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: 0 Health Official Signature: Date: / (733 Revised 8/21/2017 9 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 4. .I I. ,\\' MASON COUNTY COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH Build,ng Nanning Environmental Health,Community Health CLASS B WAIVER WORKSHEET 415 N.6TH STREET,BLDG 8,SHELTON WA 98584 (State and Local waiver forms required) SHELTON:360-427-9670,EXT.400- BELFAIR:360-275-4467,EXT.400 ELMA:380-482--5289,EXT.400-FAX:360.427-7798 APPLICANT NAME &e CO,C t3 T E`Ci4)D4 ,cA4. WAIVER PERMIT NUMBER WAI MAIUNG ADDRESS .70 ,^AWE �tit..t Am Drive, - Vt, CITY [lel j'V`%( j//� STATE WA /ZIIP�� ° c5a z' SITE ADDRESS NE 8e.ar 1o( 6- CITY ,g�l}-aLV TAX PARCEL NUMBER 3 a a 13- 15 960 3 D PROPOSED DRAINFIELD TYPE [CONVENTIONAL GRAVITY ❑ CONVENTIONAL PRESSURE 1.SOIL SERIES: 5.VERTICAL SEPARATION: The soil series must be Alderwood,Harstine,Hoodsport, Up-slope vertical separation must be greater than 18" Shelton,or Sinclair Gravelly Sandy Loam. for gravity and greater than 12"for pressure. Alderwood Gravelly Sandy Loam ❑ ❑ Greater than 12" ❑ , k Harstine Gravelly Sandy Loam 0 ❑ Greater than 18" Hoodsport Gravelly Sandy Loam 0 ❑ -Determined by: Shelton Gravelly Sandy Loam 0 ❑ Depth to hardpan Et/ % Sinclair Gravelly Sandy Loam ❑ ❑ Depth to mottling ❑ ❑ Other 12( Both ❑ ❑ 2.SOIL TYPE: 6.WATER TABLE LEVEL: Soil types must be Medium Sand,Loamy Sand,or Sandy If test holes show evidence of a seasonal water table • Loam.Gravel percent must be less than or equal to 35%. above restrictive layer,a curtain drain may be required • Medium Sand 0 ❑ -Evidence of seasonal water table: Y Loam Sand Lid X o Yes El Sandy Loam ❑ ❑ 2/ 1 No o 0- Percent Gravel: -Curtain Drain required: o -Less than or equal to 35% El ig o Yes ❑ ❑ -Greater than 35% ❑ ❑ 3 No 2/ X 3 (-0 3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: (o F c Soils must be moderately well drained to well drained. O Primary Drainfield must maintain 200'from down-gradi- ro Well Drained d "X ent marine shorelines,surface waters,and wells. O sZ Moderately Well Drained ❑ ❑ -Are increased horizontal setbacks met: Other 0 ❑ Yes 12/ tf No ❑ 4. DRAINFIELD SLOPE: 8.ATTENUATION ZONE Slopes must be between 3%to 30%. Gravity Is only allowed on slopes from 3%to 15% A 50 foot horizontal attenuation zone is required Less than 3 Pressure is allowed on 3%to 30%. down-gradient of the primary drainfield. % ❑J ❑ -Is there 50 ft or greater between the down 3%to 15% L]l gradient side of primary drainfield and 16%to 30% ❑ El property boundary: Greater than 30% ❑ ❑ Yes No ❑ ❑ The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable �� I(6,.c7_ f prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. P-oof of Recording: THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE. updated 3/2/2017 ~ w Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC Effective Date: July 1,2007 Revised April 2017 On-Site Sewage Systems (Chapter 246-272A WAC) Request for Waiver from State Regulations Section I. I (completed by applicant) Name: (I) / Local Health Department i District (2) Vera td C-I C............_. __.._..... (see instructions) Address: .?D NE ..0 e." Telephone: (SQ) f q 9 Signature: Property identification: (3) PO-fct. _.._._ s�,.s ....is-.... /©o&-o...._- _- Section II. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) I Waiver Sought: (6) .._ _.___....._....-- -------- 246-272A— 0230 Subsection: TABLE VI 36" OF V/S FOR GRAVITY 18" OF V/S FOR GRAVITY OSS Justification(mitigation measures to be provided): (7) COMPLETED CLASS B WAIVER CHECKLIST ATTACHED, (OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN. ZONE (AFN: 2(f6529 ) Section III. I (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (10) Seer cri fti ..4 Glass Q k .Ql y,€ir 4,60 . Type of Waiver: (11) [ ]Class A [.Class B [ ] Class C—Request DOH review before granting? Yes_ No Neighbor Notification: (12) Required? Yes_ No_ If needed, are agreements, easements, etc.properly filed? Yes No Section IV. I (completed by health officer) This Request For Waiver From State Regulations has been reviewed according to the provisions of Chapter 246-272A WAC On-Site Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability to provide public health protection at least equal to that provided by this chapter WAC. [ ] Denied [ [,Approved /Granted—Subject to all comments,conditions and requirements oted in Sections II and III. Local Health Officer (1.1) Date: J "2-0- DOH 337-021 Page 26 of 32