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Home My WebLink AboutWAI2023-00038 - WAI Health Waiver - 5/1/2023 415 N. 6th STREET,SHELTON WA 98584 MASON COUNTY SHELTON:360-427-9670,ext 400 4111114711 COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 Building,Planning,Environmental Health,Community Health ELMA: 360 482 5269,ext.400 FAX:360-427-7798 Application for Waiver or Appeal . 11 Amount Paid: Receipt Number: pECEUTT WAI (��3 - 0 O n MAY n 2023 �(? u 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 ��/�_ 2 Telephone&4 Mailing Address ] _ C\1`�� C� ��\�0 -C >.J� - City State Zip \1J ` Parcel No. t �� C C — c� — : 3 n Site Address NA:3V, , 1—C Subdivision Name and Lot �3 G()'�T \--CA PART 2: Nature of Waiver/Appeal cie 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 S CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE t \\)\ Applicant Signature: SVki- 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 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver (if applicable) Appeal VWaiver o None required ri Class A N/CIass 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 CONVENTIONA GRAVIT OR PRESSURE OSS. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board i ' Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN_ fi q 1 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local po 'cy has been submitted. Staff Signature: tt W tLv \., Date: Si- _25 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: ❑ 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: A7 Date: ..PM-1 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 fMASON COUNTY l_ 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 —\V-F. .() v, ) Q`-' WAIVER PERMIT NUMBER WAI MAILING ADDRESS ' I\-� \A . 1 t 1 pe-- - / • STATE V 4 - Crr 1 CRY 'l\\VC.st\c- ` ZIP ��1 SITE ADDRESS 3�CS \\' , [�U\ 1\.)J�1 W1� U�lQ ?...„.4-.)` � • CI��\ O TAX PARCEL NUMBER . \ -C'C,^~ CT.' PROPOSED DRAINFIELD TYPE X CONVENTIONAL GRAVITY 0 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 0 0 • Greater than 12" 0 Harstine Gravelly Sandy Loam 0 ❑ Greater than 18" Hoodsport Gravelly Sandy Loam 0 -Determined by: ` Shelton Gravelly Sandy Loam ) Depth to hardpan �,�``l� Sinclair Gravelly Sandy Loam 0 Depth to mottling 0 ❑ • Other 0 0 Both 0 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%. above restrictive layer,a curtain drain may be required Medium Sand 0 0 x -Evidence of seasonal water table: Loamy Sand El4 Yes ElSandy Loam z No Sa s Percent Gravel: o -Curtain Drain required: I CD -Less than or equal to 35% o Yes ro R.„,q, -Greater than 35% 0 3 No lia co z co 3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: c Soils must be moderately well drained to well drained. O Primary Drainfield must maintain 200'from down-gradi- rfo onent marine shorelines,surface waters,and wells. Well Drained 0 Moderately Well Drained -Are increased horizontal setbacks met: \ zj Other 0 i 0 Yes `� No 0 0 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% 1/4_❑ -Is there 50 ft or greater between th wn 3%to 15% M gradient side of primary drain and 16%to 30% ❑ CI property boundary: Greater than 30% 0 0 Yes No ❑ CI. The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildabl - //� prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: ,,-�I(-1 Le7 parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recording: e • THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBS1 E. \ updated 3/2/2017 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. J (completed by applicant) Name: (1) Local Health Department/District (2) (see instructions) Address: k\ '—' Telephone: ( ) Signature: Property Identification: (3) - ,�, 3 Section H. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A— 0230 _ 24" or v/s FOR PRESSURE (OR) 1 ) 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: ) section ml.; (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 [ ]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 j.Approved/Gra ted—Sub' t to all comments,conditions and requiremen ynote in Sections II and III. Local Health Officer (13) Date: / DOH 337-021