HomeMy WebLinkAboutREQUEST FROM STATE WAIVER - SWG Application - 2/12/2004 On-Site Sewage Systems (Chapter 246-272 WAGS
Request For Waiver From State Regulations
SECnON I. f COMPLETED BY APPLICANT S
r` l Y�F Local Health Department/District(2)
Name:(1)^ o.
Address: Y•d. � 1
�`c��c�.�(i eve � �' � LV� - • - G�� �,Ur�C
Telephone:( ) 1-'
Ilk
Signature:
Property Identification:(3)
SEMON U. E COMPLETED BY APPMANT
WAC Number:(4) C Requ{{cement•(S) W 'ver Sou$ht•(6)
.�� �rCk�n� \ act_r'S /2`C`IC\Cti�
246-272- 5
Subsection: .�- e �,b r l OU
jugification(Mitigation m ures to be p{ovide)-(7)
SECTION III. COMPLETED BY HEALTH OFFICER
Review Criteria(11) Mitigation Measures('m addition to mode proposed):(9)
Comments/Conditions:(10)
Type ofWaiver..(11) OC1assA B OClassC-RequarDONrevkwk(2=granting? Yes_ No_
Neighbor Notification:(12) Required? Yes No (fneeded areagretments,easenwna.t1apropefh'IZed? Yes No
SECTION IY. QED BY HEALTH OFFICER
:This Request For Waiver From State Regulations has been mvkwed sococdiog to the provisions of Chapter 246-272 WAC On-She Sewage System.
Tbc review criteria appl'ad.and the mitigation measures proposed and/or required.have beech evaluated for weir ability to provide public health
protection at kast equal to that provided by this chapter WAC.
Approved/Granted-Subject to all comments,conditions and requirements noted in Section II and III.
0 Denied �}
Local Health Officer(13) Date: �� (/
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
i eraottal Health
Environmental Health Water Quality
LOCAL(360)427-9670
Application for Waiver/Appeal BELFAIR(360)275-4467 &4468
TOLL FREE 1-800-562-5628
FAX(360)427-7798
Amount Paid s�
Receipt Number:
Instructions
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PART 1: Applicant/Parcel Identificat+iion
Name of Applicant 1 lh o�n'G�`�`�� Date I. C-6
Mailing Address ��. o� 1 Telephone O �- ,] 1'�-
CSIAL
Assessor's Parcel Number ���
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
� 13Sanitation
Requirements is
On-Site Sewage Requirements
s ❑ Building permit review policies Solid Waste Requirements
❑ Location, WAC 246-272-09501 11 Group B Water System Requirements
❑ Holding tank WA 246-272-12501 ❑ Water Adequacy Requirements
)< On-Site Standards 17 Enforcement Timelines
❑ Certification contractor(pumper, ❑ Departmental Determinations
designer, installer, O&Mspec)requirements 0 Other
script•on of Waiver/Appeal(in lude justification,additional material maybe attached):
C
�e• r ' eY'
Applicant Signature: Date: d�
pril 25 l997
H.%WDATAW RCHIVEIW.[IVER WP Update:A ,
PART 3: Health Department Evaluation(Staff Use Only)
I A. Type of Determination Required: I B. Type of On-Site Waiver(if applicable):
❑ Appeal Waiver ❑None required ❑ Class A Class B ❑Class C
2. Identifrcaton of Specific Code/Standard/Determination(include date of determination or latest
codelstandard revision):
3. Nature of A peal: 24 co IV,v
JUtr ,S
4. Hearing Official:
❑Board of Health KHealth Officer
❑ Pollution Control Hearing Board ❑ Health Services Director
❑ Certified Contractor Review Board ❑Environmental Health Manager
5 Mit sting Factors:
it!k\N
z 9 '
6. 1 have reviewed this waiver/variance request. It is complete, and mitigation required by state and local
policy has been submitted. j (�
�Staff. 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 grunted. This decision is based on the following findings and conditions:
❑ The hearing official has determined that approval of this request could potentially have an adversely affect
public health and is hereby denied. This decision is based on the following findings:
Hearing Official Date:
H.•IWDATAWRCHIVEMA/VERWP Update:April 25.1997
• .r
�9
APPENDIX A
CLASS B WAIVER OF ONS1TE SEWAGE REGULATIONS WAC 246-272
WORKSAEET FOR DETERbWMG A REDUCTION IN VERTICAL SEPARATION
This wed is used to determine if a site qualifies for a reduction in vertical separation under We Class B Waiver. Please fill out
the wodmhed in its entirely. Incomplete woricsheels are returned to you and will cause delays in your permit application.
Part I.APPlicant Information
Name of Applicant: Date:
Site-Address:
Mailing Address:
city; \ lz> State: W� Zip: "1 S44
01
AssessWs Parcel#• \,�N0S62 -�� 0c) SWG#
Part Z:Checklist
1) Son Series 3) Check the soil structure.
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-.••.}•.v:n:�<•i}:<}i%":iii:+::._:::::.:..._...vv:::vv}.vim}:::::::::.�:•::::::::. ..v..:-... i i :
4t'4:_r.::.<<•}}�:.;a<:'f<;:;.:;r :;, :r:::<::::.;:•} I�:Z17 = :Q(•. �C{:< :.
.be
'fie aE. -�e�:�. c�•;.,; :.<.::
... ......
Single Grained or weak........................
Well suucft eel . ❑
Oal« ........ ❑
Aldewood Gravelly Sand loam ................. 0
Basting tirtvelly sand Loam ................... (3 4) Check percent slope of the primary/reserve drainfield
Hoodspott Gravelly Sand Loam.................. (3 area.
Shehon Gmrdly Sand loam ..................... ❑
Sinclair draveily Sand Loam .................... ❑
Other ....... ❑ x
2) Cheek the soil type: less than 3% ................................. ❑
3%-15% .................................
..�
16%-30% .................................. ❑ i
(coder than 30% ............................. ❑
5) Check the a vertkdOEM=
aratioa
Loam ...................................... ❑.
L =V Sand ................................ +�❑
Sw*L,oam .............,........ ......... !zy
Paced Gmvd by Volanaw ❑
Less than cr equd to 60% .................. Less than 12' ..............................:
greaterWag 6o%......................... ❑ 12-18" ....................................
Omdwthan18" ............................. ❑
Detamined by.
_ Depm to Ilacdpaa.........................
� .:
1 Depth to Mottding o....................... ❑
'iJ Both ... .... ................... 0
•w
6) Check the dmin gre of the so1L 10a) Check Horizontal Atl anation Zone.
h ;TiH
Is there Icss:dim 50 fed between
e down gradient side Of
Well Drained .......................:........ ❑ .? : <a: the proposed primary and reserve dminfield arras and the
Moderately well Drained....................... . �
tr#T;,. Property boundary?
Other ❑ Yes ........................................ ❑
No......................................... �
7a)Check water table level.
If es,the applicant will need to
Y aPP provide a recorded
covenant or casement prior to food P acceptance of the on
site sewage application.
10b) Record 50 foot zone ona dd.
Is the water table:
Above360 ..................................
Above240 .................................. ❑
Above 12 ....... ..................... Q :> <{ .•, leiikTaccor
A!AM .ram:;:�{.T�....�....,f Tr»:•:-�.�:s:.::•�',:,;.;t,,t,:c':: T•`•,3?:
..., a:. ... .. .:. .....
7b) Is a curtain drain proposed up slope of the primaryMf
Is the owns aware and in draiafield area. agreement with these terms?
Yes ...................................... ❑ ::t;?::`cv• (home owner initial )
No........................................ '<°'-:'• Yes ......................._................ . i
No......................................... ❑
8) Is the property on marine shoreline?
Is the 50 zone recorded on the deed?
_ •:'3 yyv..:v __ ..nti n.-. }`T%.,t7v-"--.,.r.:w
: Yes ...............` .................. .Ter
Yes ........................................ ❑ 11) Check prozimlty to welts. : a '
NO.... ...................................a ^'.
If ye;-hbdicate the distance fmm the shoreline to primacy
dcainfield arras fed.d i
9) Me there any fresh water bodies w'ithhc,or adjacent to,
the ro _boundaries? Indicate the smallest distance from existingor proposed wells to the
.• primary or resew5 drainfield fat.
W 1Z V �b 04�G\
Yes ........................................ 0
NO.........................................
Ifyrs,tadieate&tanoe from shoreline to primacy do
sew vie onus: . fed.
Designer Comments:
art 3: Certification and Approval
Applicant Certification:
i certify.to the best of my knowledge.that the above information is true and correct. I acknowledge that I am solely responsible for maintaining the
integrity of the primary and reserve drainfield areas;and that destruction or damage to the drainfreld area may result in immediate rescinding of the
ite sewage perm
As� '` 1
—C6
Date
Designer
Date
Applicant
Health Department Review:
preliminary Review For Design Submission: Approved ❑Denied
Environmental Health Sanitarian Date
Waiver is❑Approved 0 Denied
Environmental Health Sanitarian Date
Comments:
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