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Home My WebLink AboutWAI2023-00032 - WAI Health Waiver - 4/27/2023 415 N.6 STREET,SHELTON WA 98584 trill .F. MASON COUNTY SHELTON:360-427 9670,ext 400 '2) COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 ELMA:360-482-5269,ext.400 �`1 Suamng.P[ammms.cnvirenmma!Health.commumo Health FAY:360-427-7798 Applica ion for Waiver or real d Amount Pad: �� Receipt Number: do WAI 1.023 0e612.. Instructions: 1. Complete Parts 1 and 2. No determination can be made until these pads 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 Courtly Public Health for review. PART 1. Applicant & Parcel Information'' // Name of Applicant Pan V �1/icn1 [la Telephone 1-W-S-1-199- 121z Mailing Address City_ I aComa_ — State �k - Zip -1`l�(�S Parcel No. a 3 4_ - ± 'o- CI _a _a Site Address g vo_ a�^ �R Ili Subdivision Name and Lot PART 2: Nature of Waiver/Appeal 0 Food Sanitation Requirements Class B Reduce Vertical Separation 0 Group B Water System Regulations O BuildingioPermit 246-2w Policies ❑ Water Adequacy Requirements O Hod ank AC 2 246-272A-024010 ❑ Enforcement Timelines O Holding Tank WAC Standards ❑ Departmental Determinations O Mason County Onsite Requi ❑ Other O Contractor Certification Requirements (Installer. Pumper, O&M Specialists) Description of Waiver/Appeal (include justification, additional material may be attached.). REDUCE VERTICAL SEPARATION FOR ' nlf1SSbtkE _ OSS CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE A Fir .. -la.'7r7Z 04 /-f 91rt;,r Date Applicant Signature. Revised 8210.017 This form may be scanned and available for public view on the Mason County Web site. Page I f PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver (if applicable) ❑ Appeal I./Waiver Class A riClass B u Class C/Waiver ❑ None required - 2- Identification of Specific Code/ Standard/ Determination TASnclude date of determination or latest Code/Standard revision): WAC- E VI 3. Nature of Appeal: REDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL GRAVITY OR PRESSURE CSS. 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Colluded Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board d Environmental Health Manager 5. Mitigating Factors: CLASS B WAIVER CHECKLIST (MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECI ARATION COVENANT FOR OSS ATTENUATION ZONE (AFN 1Za y Tv6l ) 6 I have received this waiver/appeal request. It is complete and mitigation required by the state and local polio seen submitted. 7�� eil Staff Signature: A% Date: /LU�( �� PART 4: Determination of the Hearing Official ali._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: �l' Date: g/Z•71.4 Health Official Signature:_ Revised 8/ 1/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 4fi r\ MASON COUNTY MASON COUNTY PUBLIC HEALTH COMMUNITY SERVICES \ � yN ;meMen a„vemeruaEttO�wasasaa rest CLASS B WAIVER WORKSHEET s 0GI (State and Local waiver forms required) SNEL ON 3604375610.EXT 4m-6:L;A,n 369 27O4468 DXT.480 I-.MA 3 6 04 8 2-526e Err ADO-vAX 360-431-7796 wPnuNTNAME PO V'I II4 WASVE3 PERMINIMnrn WAI MAINtO ADDROS lal S. 9 ' tt _v recliThx- STATE _ gVIOS gab .96 LRCER(OC-r& OK — Bel%'r T4.PARCEL NUMaEa AA Soy--7b-'lane ,,QOP05EDORANnetp-Yet ❑ -DN,tNTIONAAawAVITY ICCISONTIONALPRESSURE 1.SOIL SERIES: 5.VERTICAL SEPARATION: The soil series roust he Alderwood,Harstme Hoodsport. I Shelton.orsmdairErzvelly Sandy Igam Up-slope vertical separation must be greater than 18" . for gravity and greater than 12'for pressure. Alderwood Gravelly Sandy Loam _ 21J Lr,,.,/ Greater than 12" 1 E Harstine Gravelly Sandy loam . El ElGreater than 18 -__ H000sport Gravelly Sandy Loom - ❑ 0 -Determined by: J Shelton Gravelly Sandy Loam ❑ 0 Depth to hardpan _ a mi Sinclair Gravelly Sandy Loam ❑ ❑ Depth to mottling ❑ ❑ Other .. ❑ ❑ Both ❑ 0 2.501L1YPE: 6.WATER TABLE LEVEL: Soil types s be Medium Sand,L y S nd.or Sandy if holes showevidenceofa water table m.Gravel percent must be less thanequal to 35%. ah , restrictive layer. in d y b apuned Medium Sand . 0 D 2 -Evidence of seasonal water table: F� v Yes 0 l err loamy Sand J H, -- Ll LM Sandy Loam _ _ y -CN . " -- '' -Curtain Drain required: 0 p- Lesshan or r;-r�o Yes - ❑/ ❑p -Greeter t orequalto 35% w Ly1 Lam_ Greater than 35% ❑ 0 % No_ 3 SOIL DRAINAGE: ro 7 HORIZONTAL SETBACKS: '. S ls must he moderately well drainedned to well drained Pumary2 fildr t 2oOfale .rev s. 0 r r wells. F Well Drained - ❑ El -Are increased horizontal etb k met: Oth Moderately Weil Drained El ❑ Yes Other - No _- 0 ❑ 4. DRAINFIELD SLOPE: 8.ATTENUATION ZONE I Slopes must be;erween T%to3o%. Gravity is only allowed on slopes from 3%to 15%. A 50 foot M1Ornontalatteouatlon zones regmrec Pressure is allowed on 3%to 30 b. down-gradient of the primary drainireld. Less titan 3% .. [./ ❑� -Is there 50ft or greater between the down ❑/ p( gradient side of primary drainfield and 3%to 13% rt boundary: .LAN•//15%'0 30.,- 0 ❑ property Greater than 30% _ ❑ ❑ Yes ❑ ❑ No The 50 foot nonmetal attenuationbe e. d tl on the d d ofth property s unbuildable � '/�� r roval.The attenUorrOn zone is nor to be for the contrucrion of prior ng areas. 6[saxp v+oe rroaer aye MASON e n,nerr mos agreet touc roads, decks, einns.o: AFN: L eor.d srzrzr. p k 9 vehicular M1 , hsurely THI 31 PUGBSrt 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 (I) Local Health Department I Dimt mt (2) Daniel Ila _._(see instt ctions) _ — Address: / 17 _ _5- 9-'4% fi -I ametWp gbvoS Telephone: Q' 's 1�q _ a tZ- Signature: Property entification: (3) Pe rct IACsoil 76 9t 60 350 yC LA- CAIPGE DRe,ELF/4/R Section II. j (completed by applicant) WAC Number: (4) WAC Requirement:qui (5) Waiver Sought: (6) 246-272A 0230 24' OF V/S FOR PRESSURE ) 12" OF V/S FOR PRESSURE OSS 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: ZZOt FOG Section III. I (completed by health officer) Review Criteria' (8) Mitigation Measures(in addition to those proposed) (9) Comments/Conditions: (10) 5p> CigiE e 1[tl voiksYr;X/'r. - -- Type of Waiver (ii) [ ] Class A .Class B [ ] Class C—Request DOH review before granting? Yes_ No Neighbor Notification: (12) Required? Yes No _ lf needed, are agreements, easements, eta properly filed? Yes — No Section W. I (completed by health officer) - ing to e ons te Sew ge Systems.For The review Prom rtate Regvla and the mitigation measuresns has been reviewed s proposed and/ort regwr d,have ben eva u ed f rr ther 246-272A WAC ir ability to page ublic Tht te criteria applied,u to provide public health protection at least equal to that provided by this chapter W AC. [ ] Denied 'a Approved / Granted—Subject to all comments,conditions and requirements n ed in Sections II and III. Date: L6774 Local Health Officer (13) — Page 26 of 32 DOH 337-021