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Home My WebLink AboutWAI2021-00129 - WAI Health Waiver - 10/22/2021 aw MASON COUNTY COMMUNITY SERVICES Building,Planning,Environmental Health Community Health 415 N 6�Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 C Belfair: (360)275-4467 ext 400 : Elma: (360)482-5269 ext 400 FAX (360)427-7787 Application for Waiver/Appeala Amount Paid: 0 6 Receipt Number: 991 .lam 5 Instructions .... ........... .. ....... 1 Complete Parts 1 and 2. No determination can be made until these parts are fully completed. 2. Fees maybe 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 Kw' f�� `` �`S� Telephone Mailing Address of Applicant Y (3ox Z936 p p City State wp, Zip 12-digit Tax Paroel No. _3 _2 Z O 1 _ O _ O _c7 3 O Site Address 2-O92T, A);5 tl sl o e R�• , Rat^ d", t"1A9S, Subdivision Name and Lot 0l- C— �L' Q (zM-L—L ( 1b 30~ Sf W � S o4- PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class S Reduction in Vertical (Installer, Pumper, O&M Specialists) ❑ Separation ❑ Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations 5( Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Orate Standards ❑ Departmental Detemlinations ❑ Other Description of Waiver/Appeal (include justification, additional material may be attached.): Applicant Signature: Date: O_ 2Z- 2t S:\EH Forms\Waives-Appeal Meson County Local Revised 1/200017 Page 1 of2 l PART 3: Public Health Evaluation (Staff Use Only) t. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑Appeal �iver ❑ None required p6lass A ❑Class B ❑Class C 2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/ Standard revision) vn/ LJG— 3. Nature of Appeal: V v �) l• P4dtico * Sti�c (e hum AI A* GfVlSiO W� `H 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director Cl Certified Contractor Review Board environmental Health Manager 5. Mitigating Fact a: C(�$7Kti OVI -)YJiricOytq" IY a. 0 7Yre 5^0 w K tA'S n w yy W-CA 1 6. 1 have received this waivertappeal request. It is complete and mitigation required by the state and local policy has been submitted. Staff Signature: Date: 11 I31-0 7PA T 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: ❑ The hearing official has determined that approval of this request could potentially adversely effect public health and Is hereby dented.This decision Is based on the following findings and conditions: Hearing Official Signature: Date: (1 vl i� 971 ` 7:1&H Forms\Waiver-Appeal Masm Comty Local Revised 120=7 Page2of2 on-Site Sewage Systems (Chapter 246-272A WAC) Reouest for Waiver From State R MatiOus Section L (completed by applicant) Local Depamoemt r District (2) Name: (1) see iasnucdons Address: _ __ •Q,O.__�ox 293b --- — Y. � Z8 Telephone: (41S) 53o- -l2S`F --... Signature: - prapaty cation: (3 ,f]6�*# '3LI.ol -S�- o t�130 �1 wwnP1 C.bf4r.(�.�({_ t Section U. (completed by applicant) WACNumber: (I) WAC Requirctnent: (5) Waiver sought: (6) p('essws3c�- Seaaa l `iP^h 246-272A— 02 I 0 0) ��.c r�...a} be 50�Vsa1�. Subsection: Justification(mitigation measures to be provided): (7) ssg- section M. I (corpleted by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (18) Type of Waiver. (/]) [ s A [ ]Class B [ ]Class C—Request DOH review�granting? Neighbor Notificati : (12) Required? Yes No_ lfneeded,are agreements,easem nU,etc properly filed? Yesz No_ Section lV. I (coonpietedby health officer) This Request For Waver From Sure Regulabcua 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 heal/�lf/�,��_tection at least equal m that provided by this chapter WAC. [ )Denied "Approved/ r t object to all comments,conditions and requiremea cool in Sections B and lu. Local Health Officer (13) Date. 19 Application for Waiver/Appeal Mitigation 9-28-21 Owner: Kim DeFriese Phone:(425)530-7254 Mailing Address: P.O.Box 2936,Belfair,WA 98528 Site Address: 20922 NE North Shore Rd.,Tahuya,WA 98588 Parcel Number: 32207-50-00930 Property Description: Olympic Beach TR-11 B&Tax 1200-L2 TR 3 of SP#1764 S 40/4 State DOH Waiver Sought: Reduce horizontal separation between owner's well and pressurized transport line from 50' to no less than 251. State DOH Mitigation Measures: I a)Transport line installed in a casing of at least Schedule 40 PVC within 50 feet of well. Transport line uniformly supported by pressure-grouting annular space with sand-cement grout or bentonite,or casing spacers or skids installed consistent with AW WA PVC Pipe Design and Installation Manual M23.Underground installation of line consistent with ASTM D 2774. 2a)Transport line leakage test consistent with ASTM D 2774,except line should be pressurized to 150%of the system's design operating pressure,but not less than 70 psi,and pressure must hold for 1 hour. 3a)Notify well owner of proposed encroachment if there are no existing covenants or easements establishing a control area.—"Only the Owner's own well is affected,neighbor wells are over 50'from the pressurized transport line