HomeMy WebLinkAboutWAI2022-00142 - WAI Health Waiver - 12/28/2022 :. 415 N.6t`'STREET,SHELTON WA 98584
. MASON COUNTY SHELTON:360-427-9670,ext 400
10a
_ :_ , : COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
I3u I,Iu Herdth,Community I Ie.t.th
ELMA:360-482-5269,ext.400
• v•ttivrr�N; FAX:ilegrilitign for Waiver or Appeal
Amount Paid: Receipt Number: lam
WAI "AU,• d0 P
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. Applicant & Parcel Information
Name of Applicant �/ c # /e7 h Telephone 303-34'Q. #727
Mailing Address 3 q3'4 Naz* s o Doc,J
City n4.I-4Av State Lid. Zip ql P s-d y
Parcel No. .2 r ,j- -_ if/ 2 -- C) 0 S
Site Address
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
Class B Reduce Vertical Separation ❑ Food Sanitation Requirements
El Building Permit Review Policies El Group B Water System Regulations
❑ Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements ❑ Other
(Installer, Pumper, O&M Specialists)
Description of Waiver/Appeal (include justification, additional material may be attac�:-.
REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY OR . 'ESSURE O:S
CLASS B WAIVER CHECKLIST
RECORDED DECLARATION OF ATTENUATION ZONE
Applicant Signature: CI W�
(--fa Pixi Date: ir)Rev
�ZZ
This form may be scanned and available for public view on the Mason County Web siite.1sed 8/21i20I7
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Appeal v'Waiver None required n Class A VCIass 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
PRESSURE OSS.
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board t2' Environmental Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN)
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN '2,1 -j l 9 )
6. I have received this waiver/appeal request. It is complete and mitigation required by the
state and local poli =s been submitted.
; (,t„�Staff Signature: f � Date:
PART 4: Determin.tion of the Hearing Official
A_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 denied. This decision is based on the following findings and
conditions:
Health Official Signature: Date: 1/2- r/2-3
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 2 or 2
•
MASON COUNTY 0 COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH
Building.Planning,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 NAME 7'> Q, a/6"/
fr* /C S' 1 ``WAANER PERMIT NUMBER WA
MAILING ADDRESS 3 (S / J E A Qae„�h rsld',4� / /r Sve
CITY r f-1, /d /_/, qr c �VV/STATTE
,I , ((//�� LIP
SITE ADDRESS -s'd/s'rd CITY
TAX PARCEL NUMBER 2 2 t( ...5.--- `" T c.)O . PROPOSED DRAINFIELDTYPE 0 CONVENTIOVAI GRAVITY [CONVENTIONAL 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 ❑ ❑ Greater than 12" V N.
Harstine Gravelly Sandy Loam ❑ ❑ Greater than 18" El ❑
Hoodsport Gravelly Sandy Loam ❑ 0 -Determined by:
Shelton Gravelly Sandy Loam ❑ 0 _ Depth to hardpan Of ❑
Sinclair Gravelly Sandy Loam , b._ Depth to mottling ❑
Other 0 0 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 0 _ -Evidence of seasonal water table:
Loamy Sand ❑ 0 o Yes a ❑
Sandy Loam ,E:1 3- No gr -D
Percent Gravel: ) -Curtain Drain required: p
-Less than or equal to 35% 13' Yes ❑ ❑
-Greater than 35% 0 0 . No 2r E;L`. g
3. SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: ro
ro
c
Soils must be moderately well drained to well drained. 1 p Primary Drainfield must maintain 200'from down-gradi- m
� z ent marine shorelines,surface waters,and wells. O
Well Drained 1E({ ❑ s
Moderately Well Drained 0 ❑ -Are increased horizontal setbacks met:
Other 0 ❑ Yes A la
4. DRAINFIELD SLOPE: No ❑ fl
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 0 -Is there 50 ft or greater between the down
3%to 15% A ❑ gradient side of primary drainfield and
16%to 30% ❑ ❑ property boundary: -._.,
Greater than 30% ❑ ❑ Yes ❑
No El ❑
The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable l 3
prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN:
2.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. up 3/2/2017
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lir F 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)
e ow (see instructions)
Address: 355 if No
� ic14 17514411 nk.
S- r4. /4 Z.. Vary
•
Telephone: (&J ) 341q_ 6 7 Z7 •
Signature: --(...Jci. (mq 4
Property Identj on: (3)
2/ 2s— y2. Oao
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
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: ,^r,,1Ci34. 1eY )
Section III. J(completed by health officer)
Review Criteria: (8) Mitigation easures(in addition to those proposed): (9)
Comments/Conditions: (10)
Type of Waiver: (11) 1 ]Class A 4.Class B [ ] Class C—Request DOH review before granting? Yes_ No
Neighbor Notification: (12) Required? Yes_ No_ If needed,are agreernents, 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 V.Approved/Granted—Subject to all comments,conditions and requirements noted in Se•tions II and HI.
Local Health Officer (13) 4.1/" ' Date: V W J
DOH 337-021