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Home My WebLink AboutWAI2016-00070 - WAI General - 7/25/2016 Sc 0ON COujr� Public Health JUL 25 21116 Always working for a safer healthier Mason County PO Box 1666,415N 6th Street, Bldg 8,Shelton WA98584, BY. Shelton:(360)427-9670 ext 400 4 Belfair:(360)275-4467 ext 400 C Elma:(360)482-5269 ext 400 FAX (360)427-7787 Application for Waiver/Appeal Amount Paid: )30 Receipt Number: S(n ( WA! c≥Otio - Obo o Instructions I. Complete Parts I 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 �'ey th TY-`42_( t Telephone �la� 4q- Mailin{g�Addresss^ofApplicant �e cK_s C1e 1) City D e .-t 0.tr State_____ Zip 1 b Std 12-digit Tax Parcel t— ' w No.{-2- �-- O 2S_ --- � 5.... -- O ' .O & 3 6 SiteAddress 4-70 ) k g stj Subdivision Name and Lot PART 2: Nature of Waiver/Appeal Class B Reduction in Vertical Separation O Food Sanitation Requirements ❑ Building Permit Review Policies O Group B Water System Regulations ❑ Location,WAC 246-272A-0210 O Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Onsite Standards O Departmental Determinations ❑ Contractor Certification Requirements O Other (Installer,Pumper,O&M Specialists) Description of Waiver/Appeal(include justification,additional material may be attached.): A\' r'+c.y rQ 'tc7r a 9t) Q'{r2atttct_+ o✓y ZOv e. ore r u Lo re 3 a ofpl f- a- C-1 5 "D" ua)tv r S-ef+1 S , Sf 'i c &( I rah Applicant Signature: Date:7-&22 b O t` Aae, e —r y & Revised 1/22/2015 This form may be scanned d available r public view on the Mason County Web site. Page 1 of 2 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑ Appeal ✓ Waiver ❑ None required ❑ Class A 0 Class B o Class C 2. Identification of Specific Code/ Standard/Determination(include date of determination or latest Code/Standard revision) 246-272A -0230 (TABLE VI) 3. Nature of Appeal: REDUCE VERTICAL SEPERATION FROM 24"DOWN TO 12" FOR CONVENTIONAL PRESSURE 4. Hearing Official: ❑ Board H l ❑of Health Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board ✓ Environmental Health Manager 5. Mitigating Factors: MEETS ALL CLASS B WAIVER REQUIREMENTS AFN: Z> S1 LP °I L.P (RECORDING FOR ATTENUATION ZONE) 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitte . Staff Signature: Date: rJ 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: AMC O 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: Revised 7-2013 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 On-Site Sewage Systems (Chapter 246-272A WAC) Request for Waiver From State Regulations Section L I (completed by applicant) Name: (1) Local Health Department/District (2) -_ --_ l r\ (see instructions) Address: Telephone: ( �I-�G -I) I ( �s —— Signature: ' property Identification-. 3)• y�S [� V� alao� -'IS- Oct/30 Section II. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) V cs4tci $ €a� 246-272A— O a t rI t C1t'� 5 x��sh r u_ce Subsection: - ov Q(-e-rs e ,nau9E oe�i Justification(mitigation measures to be provided): (7) wntY W U -F t av a a. LI - It a-vea tno rocww(S or %occILti4aa4 , bçec an 3 n e and Section M. pleted by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (10) Type of Waiver. (11) [ ]Class A rlass B [ ]Class C—Request DOH review before granting? Yes— No_ Neighbor Notification: (12) � �q Required? Yes- No X If needed are agreements,easements,etc.properly filed? Yes No_ L&`%Le 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 [4 ved/Granted bject to all comments,conditions and requirements noted in Sections II and III. Local Health Officer (13) k Date: =fI 19 �ASoN COU�y� MASON COUNTY PUBLIC HEALTH Public Health CLASS B WAIVER WORKSHEET Always working for a safer healthier Mason County (State and Local waiver forms required) PO BOA 1666.41S N 6th Street,(Bldg 8)-Shelton WA 96594 Shelton:360-427-9670 eM400 BBeifalr:X3602754467 eM 400 APn1CANTNAME KeJ'w. • • .2-j Cr WAIVER PERMIT NUMBER WAI MMLINGGAQADORESS l E C ccY-sdeThr. c1TY dJe\4� ,V_ STATE W/'� ( aP C1 b s�"� SnEADDRESS O t LY a._____________ TA%FARCft NUMBER 2'Jl (7 x_5--'15 -0O0 3O PROPOSED DMINFIELDTYPE Q CONVENTIONAL GRAVITY 'CCONVENnONAL PRESSURE 1.SOIL SERIES: 5.VERTICAL SEPARATION: TTY` 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'................................................................dy jkr Harstine Gravelly Sandy Loam....................._............. Greater than 18'............................................................ 0 ❑ LI` Hoodsport Gravelly Sandy Loam................._.............0 LJ -Determined by: Shelton Gravelly Sandy Loam.......................................❑ ❑ Depth to hardpan..................................._....................... ❑ ❑ Sinclair Gravelly Sandy Loam.......................................❑ 0 Depth to mottling.......................................................... ❑ ❑_ Other ...........❑ ❑ 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 ofseasonalwater table: LoamSand....................._................_................................❑ Yes......................................................................................... SandyLoam........................................................................1� No.......................................................................................... Percent Gravel: �,,f -Curtain Drain required: -Less than or equal to 35%..............I........................ 13l 3 Yes.................................................... .0 -Greaterthan35% -Greater than35%................................................ -D No.........................................................................................../1q 3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: Soils must be moderately well drained to well drained. I Primary Drainfield must maintain 200'from downgraS- tM,,t ent marine shorelines,surface waters,and wells. WellDrained.............................................................._...... l!y "C Moderately Well Drained............................................... ❑ -Are increased horizontal setbacks met: Other .............. ❑ 0 Yes........................................................................................ 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 Pressure Is allowed on 3%to 30%, down-gradient of the primary drainfield. Less than 3%...................................................................... e❑ JJ,. -Is there 50 ft or greater between the down 3%to 15%......................._..................._............ y ................ Ist gradient side of primary drainfield and 16%to 30%......................._..............__........................... ❑ ❑ property boundary: Greater than 30%.............._..._...................................._.. ❑ ❑ Yes.....,.......,.........._................_......................_............ ...._._.mil No.............................._......_..............................._............_. ❑ The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios. AFN: l parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. PFaaroiRemrdlna THIS FORM MAYBE scANNED MDAVAILASIE FOR PUBLIC VEW ONTHEMASONCOUNTYWEBSITE. update 2/2/1015