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Home My WebLink AboutWAI2022-00050 - WAI Health Waiver - 4/15/2022 415 N. 6th STREET,SHELTON WA 98584 MASON COUNTY SHELTON:360 427-9670,ext 400 _. I!• g I COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 ELMA:360-482-5269,ext.400 • '� ,� Budding.Planning.Environmental Health.Community Health p,:�►3 FAX:360-427-7798 • Application for Waiver or Appeal Amount Paid: 1:15 Receipt Number: "3-2,.. WAI IE I "t�ObS'O 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. Applicantt&& Parcel Information /C• �` Q� Name of Applicant J P:(,�' \E— 1, )�, Telephone .��)l� I 1 13O1 Mailing Address � � \ t • C City - C� F'_ State ' Zip 5, Parcel No. `3 ` — X L -- ` C Site Address . ec3\SA1;\\ V' \\\ � .0 U J Subdivision Name and Lot PART 2: Nature of Waiver/Appeal D M U 1 ' 1. t' Class B Reduce Vertical Separ APR 1 ❑ Food Sanitation Requirements ❑ Building Permit Review Policies U. Ca_. Group B Water System Regulations ❑ Location, WAC 246-272A-0210 ❑ Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-02 ,, ❑ Enforcement Timelines ❑ Mason County Onsite Standards- U Departmental Determinations ❑ Contractor Certification Requirements 0 Other (Installer, Pumper, O&M Specialists) Description of Waiver/Appeal (include justification, additional material may be attached.): REDUCE VERTICAL SEPARATION FOR CONVENTIONAL PRESSURE OSS CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE c` c".q- —licant Si Date: � A pp nature: g rJcZ C�Sy Revised 8/21/2017 This form may be scanned and available for 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 VWaiver _ None required Class A VClass B 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: REDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL CRAVITV OR PRESSURE OSS. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board ®' Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST (MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN ? 4 e, a,# 4"/ 0(),,Jit- icKt e1it 2 c Kc 70 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local po has been submitted. Staff Signature: `-' v Date: PART 4: Determi tion 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: Health Official Signature: Date: 7 evised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 0 MASON COUNTY MASON COUNTY PUBLIC HEALTH COMMUNITY SERVICES Building.Manning 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'360-482-5269,EXT.400 - FAX 360-427-7798 APPLICANT NAM , Nor\\�� \ c WAIVER PERMIT NUMBER WAI x.....N. MAILING ADDRESS . Y) \ C) • CITY STATE `1 v I\ ZIP�$\ 2.) �� SITE ADDRESS - � � ( CITY �\, � VS� TAX PARCEL.NUMRFR- \� \(+ 1 'I\ PROPOSED DRAINFIFI D TYPE 0 CONVFNTIONAI GRAVITY II CO.YVFNTI(NIAI 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 ❑ 0 Greater than 12" ® ❑ Harstine Gravelly Sandy Loam 0 0 Greater than 18" ❑ ❑ Hoodsport Gravelly Sandy Loam II 0 -Determined by: Shelton Gravelly Sandy Loam 0 0 Depth to hardpan 0 ❑ Sinclair Gravelly Sandy Loam ❑ 0 Depth to mottling 0 ❑ Other _ 0 0 Both 0 ❑ 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°6. above restrictive layer,a curtain drain may be required Medium Sand 0 0 -Evidence of seasonal water table: Loamy Sand 0 0 _ Yes 0 0 Sandy Loam I 0 3- No ® 0 Percent Gravel: -Curtain Drain required: CD-Less than or equal to 35% 0 0 flct. Yes ❑ ❑ -2 -Greater than 35% 0 0 3 No II 0 3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: ,5, _ c I Primary Drainfield must maintain 200'from V 0 Soils must be moderately well drained to well drained. I O down-gradi- ent marine shorelines,surface waters,and wells. 0 Well Drained 0 ❑ sZz Moderately Well Drained I 0 -Are increased horizontal setbacks met: Other 0 0 Yes iti ❑ No ❑ ❑ 4.DRAINFIELD SLOPE: 8.ATTENUATION ZONE Slopes must be between 3%to 30%. Gravity is only allowed on slopes from 3%to 15%. 1 A 50 foot horizontal attenuation zone is required Pressure is allowed on 3%to 30% down-gradient of the primary drainfield. Less than 3% D 0 -Is there 50 ft or greater between the down 3%to 15% I ❑ gradient side of primary drainfield and 16%to 30% 0 0 property boundary: Greater than 30% ❑ 0 Yes ....... ........ I 0 No ❑ ❑ The 50 foot horizontal attenuation zone is required to he 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: 2 o Ir parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recording: THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITF. updated 3/2/2017 I 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: (1) Local Health Department/District (2) (see instructions) Add .;\Az3 \ c.) n_Of' \. . °\2>_Tai— Telephone: ( f.-s) Signature: '-c„\\ Property Identification: (3) 1 __ \,c- \ 17X- _ ` � u% Section II. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A— 0230 24" OF V/S FOR PRESSURE (OR) 12" OF V/S FOR PRESSURE OSS (OR)' Subsection: TABLE VI 3C" Of V/S roil CRAVI-TY 1 " 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: 2i 4(4 Cc( ) Section III. I (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (10) Type of Waiver: (11) [ ] Class A [)1.1-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—Sub'ect to comments,conditions and requirements no ed in ections II and II1. Local Health Officer (13) _._-_. _ Date: S j 2 2- DOH 337-021