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Home My WebLink AboutWAI2023-00005 - WAI Health Waiver - 1/13/2023 415 N.6th STREET,SHELTON WA 98584 MASON COUNTY SHELTON: 360-427-9670,ext 400 11 COMMUNITY SERVICES BELFAIR: 360-275-4467,ext.400 ELMA: 360-482-5269,ext.400 ,�. �4 i Building,Planning.Environmental Health,Community Health • ; FAX:360-427-7798 Application for Waiver or Appeal Amount Paid:$ 1 FS Receipt Number: O JAN13n23 WAI 2- - 6(7OdS Instructions: BY 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 bq.,J 0027 SS Telephone 362 0 6 2,-1- :.'0.16 Mailing Address 6 (G)`Z 3 C`.0 v � � City V-. State • Zip y f/5 `f Parcel No. 3 l U -- k 1 -- U V Site Address k s-o Aft15--A- ( Subdivision Name and Lot t_p T Z— PART 2: Nature of Waiver/Appeal V Class B Reduce Vertical Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies 0 Group B Water System Regulations ❑ Location, WAC 246-272A-0210 0 Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 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 GRAVITY OR PRESSURE OSS CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE 1 , 4—7.'. Applicant Signature: Date: Revised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 4, PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver (if applicable) n Appeal Waiver LI None required n Class A s/Class 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 GRAVITY OR PRESSURE OSS. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board E21 Environmental Health Manage I 5. Mitigating Factors: CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE(AFN ?J T 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. Staff Signature: Date: PART 4: Determination of the Hearing Official EX.. 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: /17 Date: 1// 3 Revised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 • MASON COUNTY ;'```.1r -'';- COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH rr . Building,Planning,Environmental Health Community Health CLASS B WAIVER WORKSHEET 415 N.87H STREET,BLDG 8,SHELTON WA 98584 (State and Local waiver forms required) SHELTON:360.427.9670,EXT.400 -BELFAIR:380-275-4467,EXT.400 ELMA:360-482-5289,EXT.400 -FAX:360-427-7798 APPLICANT NAME t 6 (,-,-7 t'C.:-.S [''(� (� ( WANER PERMIT NUMBER WA I W 2" - 0000 S----- MAILING ADDRESSI-�` V .Y `I �--'L-- 1 - `�)LLf`I S I', ,' j ' J, 6 c ✓J(� CITY D CC cS^1 L-'+y L �(� / �' STATE V�,J/�.i ` ZIP / J t J SITE ADDRESS V Q�,Lq J,"`Irk- AA,I✓`S'Y)O� L...&S �1'�6• CITY v C�^�r,�4 TAX PARCEL NUMBER 3 1 k1 4—^` k.'.— q d V 2_,O PROPOSED DRAINFIEW TYPE 0 CONVENTIONAL GRA`IItY CONVENTIONAL PRESSURE 1.SOIL SERIES: S.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 a ❑ Greater than 12" It I' Harstine Gravelly Sandy Loam 0 ❑ Greater than 18" ❑ 0 Hoodsport Gravelly Sandy Loam ❑ 0 -Determined by: Shelton Gravelly Sandy Loam 0 0 Depth to hardpan ❑ ❑ Sinclair Gravelly Sandy Loam 0 0 Depth to mottling 0 0 Other 0 §ir Both q 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 0 -Evidence of seasonal water table: Loamy Sand 0 Et Q Yes ❑ c, Sandy Loam 0 No a W? Percent Gravel: ro -Curtain Drain required: p Less than or equal to 35% E _, Yes ❑, ❑ o -Greater than 35% m No I( 3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: z Soils must be moderately well drained to well drained. 0 Primary Drainfield must maintain 200'from down-gradi- ro zent marine shorelines,surface waters,and wells. 0 Well Drained ❑ ❑ Moderately Well Drained [ -Are increased horizontal setbacks met: Other 0 E 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% 0 ❑ -Is there 50 ft or greater between the down 3%to 15% gradient side of primary drainfield and 16%to 30% ❑ property boundary: Greater than 30% 0 0 Yes X ,:7 No ❑ 0 The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable Z`� 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. Proof of Recording: THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE updated 3/212017 1 .. 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) Address: ... ... .. .. Telephone: (3(a0 ) 43 Z.—1 — U 6 3,e) Signature:0 Property Identification: (3) — t Sc S\S-r cfL.. M cilk Do w t--t.,l . S.,c Section IL 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 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: Z\CtZV 3t ) 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 Class B I ]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. I ] Denied ].Approved/Gra ted—Subject to all comments,conditions and requirements noted in Sections II and III. Local Health Officer (13) Date: t/l r/�'3 DOH 337-021