HomeMy WebLinkAboutWAI2023-00089 - WAI Health Waiver - 10/4/2023 garb,' MASON COUNTY
:I I .5' COMMUNITY SERVICES
0 ae/ Building,Planning,Environmental Health.Community Health
415 N 6"Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 • Belfair: (360)275-4467 ext 400 • Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid:
Receipt Number:
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 Identification
Name of Applicant JEFF STEPHENS Telephone
Mailing Address of Applicant 3911 N 25TH ST,APT 204
City TACOMA State WA Zip 98406
12-digit Tax Parcel No. 2 2 2 1 2 n 5 8 - 0 0 0 3 4
Site Address 17861 STATE ROUTE 106,BELFAIR
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
0 Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper,O&M Specialists)
❑ Separation 0 Food Sanitation Requirements
Building Permit Review Policies 0 Group B Water System Regulations
M Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification, additional material may be attached.):
REDUCE SETBACK FROM DRAINFIELD TO SHORELINE FROM 10OFT DOWN TO 50FT
REDUCE SETBACK FROM TANKS TO SHORELINE FROM SOFT DOWN TO 25FT
SYSTEM MEETS CLASS A REQUIREMENTS. TLA W/24"VERTICAL SEPARATION W/OUT DISINFECTION
TANKS WILL BE COATED&TESTED FORI LEAKS,MEETS CLASS A REQUIREMENTS
Applicant Signature: ` P 1 C�_ rair ,,,+ti- Date:
1:\EII Forms\Waiver-Appeal Mason County Local 1_ Revised I/20/2017
Page I oft
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
u Appeal =Waiver ❑ None required vpJClass A c Class B e Class C
2. Identification of Specific Code/Sta d/DetermTi ation (include date of determination or latest Code/
Standard revision) 0z l V
3. Nature of Appeal: r� `-�6(�C id I 5 _ L cc4 -
4. Hearing Official: v( L 71:T 1`v/-
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board `K Environmental Health Manager
5. Mitigating Factors: �
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`ranik5 (oc f 4 -t 54-01
TiWi 5o , . Con,o'Iintr./
6. I have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been s 'fed.
Staff Signature: /y/"Gt- Date: 73 —V 3
PART 4: Determinat' n of the Hearing Official
FL. 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:
Hearing Official Signature: Date; /0/4f/L3
J:\6H Forms\Waiver-Appeal Mason County Local Revised 1/20/2017
Page 2 of 2
Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC
Effective Date: July I,2007 Revised April2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations
Section I. I (completed by applicant)
Name: IA JEFF STEPHENS Local Health Department/District (2)
Address: (see instructions)
3911 N 25TH ST, APT 204
TACOMA WA 98406
Telephone: ( )
Signatur .
Property Identification: (3) 22212-58-00034, 17681 SR 106 BELFAIR
Section II. I (completed by applicant)
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
246-272A— 0210 100FT TO SHORELINE (DF) SOFT TO SHORELINE (DE)
Subsection: TABLE IV 50FT TO SHORELINE (TANKS) 25FT TO SHORELINE (TANKS)
Justification(mitigation measures to be provided): (7) SYSTEM MEETS CLASS.A.REQUIREMENTS
XO-2 SYSTEM,MEETS TL-A W/QUT DISINFECTION AND HAS 24" OF V/S. SYSTEM
WILL BE TIMED DOSED AND ANNUAL 0/M REQ. TANKS COATED &TESTED FOR LEAKS
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: (2) 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 al least equal to that provided by this chapter WAC.
I ] Denied lotApproved/Grant —Subject to all comments,conditions and requirements note in Sections II and III.
Local Health Officer (13) lA_. / Date: il.//2. j
DOH 337-021 �Y(/ Page 26 of 32