HomeMy WebLinkAboutWAI2023-00124 - WAI Health Waiver - 1/29/2024 WA12o 13- ooIz L'
4:b t`b 1-
i•.I,,;
\ MASON COUNTYI
i;,. . c; COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6th 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: .2..SS p
Receipt Number: 2.3
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. ApplicantlParcel Identification
Name of Applicant MARY TRAVIS Telephone
Mailing Address of Applicant 7400 ASHRIDGE AVE SW
City PORT ORCHARD State WA Zip 98367
2 2 0 2 3 - __ 4 4 _1- 0 0 0 1 0
12-digit Tax Parcel No. — — — — —Site Address 920 E MAPLES ROAD, SHELTON
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ 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
V Location,WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
0 Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
CLASS A WAIVER, REDUCE SEPTIC/PUMP TANK SETBACK TO SHORELINE FROM 50'TO 25'+
TANKS WILL BE COATED,WATER-TIGHT&TESTED FOR LEAKS. ANNUAL 0/M REQUIREMENTS
REPLACING EXISTING OSS WITHIN 100FT OF SHORELINE AND 50FT OF WELL
Applicant Signature: Alb-1,-,..... (1,faCkYr) Date: -
Revised 1/20/2017
J:\till Forms\Waiver-Appeal Mason County.LocalPage 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal X Waiver None required XClass A , Class B Class C
2. Identification of Specific Code/ Standard/Determination (include date of determination or latest Code/
Standard revision)
3. Natur of Appeal:
ee/ Plait At* haV4101i4a4 `ft e br) ,efi, SP.pf`t- role
S(.rbc& > 4 F-tr, d-ea►n 5O./+ fo ► ctf- less thel Zcff.
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
O Certified Contractor Review Board tit Environmental Health Manager
5. Mitigating Factors:
Coy . Cc a +00.5
et c- f•014 of 'M k-5
- �"wr1 cS '(l 10.6 lat,celsr6te_ ti t ac S OP8'? 115 moo✓'9r&ova
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: ipPzez(1
•
PART 4: Determination of the Hearing Official
4—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:
4
❑ 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:
J:\EH 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 1,2007 Revised April 2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations
Section I. (completed by applicant)
Name: (1) MARY TRAVIS Local Health Department/District (2)
(see instructions)
Address: 7400 ASHRIDGE AVE. SW
PORT ORCHARD, WA 98367 _.._ ........... ..__._.,....._...
Telephone: (NO) t.Zc -I tot
... t .. ...........--
Signature: ! r
il! (.16614
Property Identific.:ion: (3) 22023-44-00010, 920 E MAPLES ROAD
Section II. I (completed by applicant)
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
246-272A— 0210 50' TANKS TO SHORELINE 25'+ TANKS TO SHORELINE
Subsection: TABLE IV
Justification(mitigation measures to be provided): (7)
TANKS WILL BE COATED, WATER-TIGHT AND TESTED FOR LEAKS. ANNUAL O/M REQUIREMENT
MEETS CLASS A WAIVER MITIGATION
Section III. I (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Conditions: (10) —Coq l_ed c1 cci1e 4Q,./&
` P..erfo.6m all.ce.. +6514My 0` S O a►�!h S at or �d� ade,
-Tanks wJ U access-blc P
Type of Waiver: (11) 00 Class A [ ]
Class B [ ]Class C—Request DOH review before granting? Yes No ie
Neighbor Notification: (12) Required? Yes No)( If needed, are agreements, easements,etc.properly filed? Yes No
Section IV. I (completed by health officer)
This 246-272A WAC On-Site
Request For Thee State Regulationsapplied,and the mitigation measures proposed and/or required,having to the provisions of e been evaluated for their ability
Sewage Systems. The review criteria app ,
to provide public heal h protection at least equal to that provided by this chapter WAC.
[ ] Denied aq.Approved /Gra d— Ject to all comments,conditions and requirements �ed in Sectiig II and Ill.
Date: 2. ?a Z
Local Health Officer (13)
Page 26 of 32
DOH 337-021
N
y AC 7 o
=co
4.
o
,O .c C N O. O C O• ••- ° , C .8 2 ... V — a,
gV •g� L% •• � % ° aD k- MO a0i ern �i u' b ° tiU
$ 'o = Q $ CY o o � Q C �c �' 8 c >
Q p p �d
2 c C 00 c N V • O CO '� N c ...5......= 8 3 V .0 .0
Q
m 2 U c
3E°-> oWo $ 0 3E °-> eun02o ° 4 3E � ee �$ 0
C yr _ N .8 C `� O•E O E.,, N .2 .0 C o.5 F , u 4.Q
° 8cn 3H�
•_ = °M, bC ° 03 < dQ 4 9p3a: Qo ?> y H °� 0c..`... Q d U '3 i
• c elC C 4.. Q O . `n C c0 C`... .0 .O C e p r_ 0 > c
CO
c d o a N o o 6)•m ° N A o o u o o N Y A• c ^ R
y E E y •3 V o ti C E v 3 V 0 .v)c E 3 v) p a c ,n V
' -IL
co a �.Z at O. o a 0 < ..= °' 5 D.a U• .9. �� = c e _
v O
E� y. ¢ • E`' db fi ¢ E d a> v ,_ Q �.�
1� V V g .0 °Mi C O y V .0 C y •C `ed `�' •C 7 O C ° x
U C o ° 3 ° 8a '° c o ° 3 8a '° 0 C or, 3 ua m_
3 o EH ° ° co$ vE os 3 °' -0 = po - EBe0E $ 1 ^ EE° se N .et =Q e aE a e v ; U v s'3 e � � U � p H �3i�
m . 5G - �« ia [_. s , Vt O i�• F u p ' ou
cn
F8eAs
N G 0 .V . b O 3 C Q0‘0. O .X e4- O 8 'fl p t O .. .. C Q p O N C
05
as `� V E v 4" «: C i0 c� ^ E t> ._ n s es e c V y " ^ v, = tow e 0
�' 0 C 0 V v, p, 9 04 c 1 a2 S •'•y O ;C
U Q a ` OG bn.g `°p. - ao 00.- 3 -a e w E •' 3 et: C E of L
_ 0 O V O y V 0 v1 p7 p r 6> O N M 7 § « N 8, O C VL.
•O > P. O WI 0 . p U 00.'O O0 O X O .0.. IS •'C .� ,.. E .r a••X O .0.. of O y ^ p y N
c—° a ,' Q `U 8 d °v 3 n �' Ei3 0)-v 3 w N p ° gU = u v �> 3 � '� —
OA •Q 0)c 'C a .• w .N t> Q a>c •p Chi ,. H.c w Y d Q O •p O .. F, ' e c ti C
fig '� aXi o U y Q 3 °'� . U d Q o z 8 Q= > Q -• .. ° ° •v
E • ae a a N a = w ° a ea ae C w o as `� E a 78. w C as . c a
; rn
rn
.� 0. 0 0. 07 N °.. M C •-. 7. 0 0. m N M 7 G — a o a N M 7 0 7
y V
>,
5a x C V
ci =.0 0 4 °6� °il "�gj 5 id o °N o d>
U _ C F N •� 0) . boo
ou
Cn ,, co c p E ° x V T 0 _ ce p
O 4. CO ...
' U O .0. o •ca C .Y ° eI O cE> C G N ° 'o c0
.� t0 V d E 8 _+ E a V y L.
p a1 0. 08 0. 4O2 �+ N .= P. y c •,vy� O °" C o•
.0 3 C y O 1J.40 C ° V.9. 0 5'E a .0 ,,• u 2 b= L.
�' E .o ., u i0 X o 0 o gq>> c c X .o o u X
> W I .0 Q a Q ` - rp P. Q G] > C C. Q N w ce
5
L
u
V
C c ? y u O
C
co g� v
0Ga cN N N
` _ C L
4.0
' ° b c
„�, •� ! O u
w3 a = ° c
V
o
c, A 0..
•x
. v� 3 n y, c0
E �a o ° ° c 35
▪ _ C "0.0
E u Ee^
4O CO cntp N OD � � l vv> G.o> c. is G.3
CI) v)4
vy
F O
= N .+> N N ..� M
r O N —
U M
� ei �_ 4? • O� .O .O
d II. �N ° 63
z
�3 V> NOE'- OF- NOE^ f 0
Q
/
PROPOSED 2 BEDROOM
*_1111
DRAINFIELD (5' OFF PROP. LINE) / /
/ A. / /
i; N i
N
'"---''. ' / , /
/ A / // /
, / / /
\\ i-M�P�Fs`, // //
1 l R� 6\ / -,c)
1 I � / /
(-
�° m /
I I \`�\�� / // /I /
APPROXIMATE7ifi / /
PROPERTY PIN , // //
BY SURVEYOR \\ \
I \,,,_,// // NEIGHBOR
I i / \ 1 st \ DRIVEWAY
1 1 / 1 1 \
PROPOSED TRANSPORT LINE j I I—'
MAINTAIN 50 + FROM WELLS /
// / / _I_ I
/ I /
I
�� / / / I N.
_—_ / 1 1 / -- / / \
��N // iN \ l %�' // / / \
/ \
\ C / \
1
\ 1
\ / \ IEXISTING //1/)
/ \ \\ / I
WELL \I / /
\
EXISTING
R1O0' ---I // \\ \I \\\ E /
d \__
NO WELL /
I // I 1 / \\ //
PROPOSED /� /�// / \ /
TANKS �h �N� -/
/ */ / \
* 1 / i\ ,,_____--
, ...,„ ," ..-— \ ± /
—_—— N Alkip - . _a
/ I l f. 401. •„fir
\ SEE SITE PLAN 2 � , ;. # '�
� ��� FOR MORE DETAIL ` •
�t
- AlaLOUIIS PAYSSE
EXISTING/ -`--.•,. .1-41114511Agss—
PROPOSED HOME AN ASBUILTI INSTALL SIGNOFF FEE WILL
BE CHARGED AT TIME OF INSTALLATION
PIONEER DIGGING, INC
CUSTOMS.It: MARY TRAVLS TEST HOLE I: TEST HOLE 2: TESi HOLE 3:
0-48 GIS 0-36 CTS l}I5 U.S
PARCEL :22023 44-00010 48+sow Cow 36+Comp. 15-30 CALI cL
SEPTIC DESIGNS ADDRESS: 920 E MAPLES RD Roo 1S rJ 48 RJJIS TJ 36 30+.MO I.
EX L PAYSSE DISCLAIMER:THIS IS NOT A SURVEY.REFERENCES INCLUDE'P PUCNRK N OUNDY FRODED
3083 E MASON BENSON RD. CR AIPFVIEW,WA 9854t DESIGNER: AL PLATS OR SURVEYS.FIELD MEASUREMENTS AND COUNTY O15 DESIGN INTENDED FOR SEPTIC
�ry PURPOSES ONLY. PROPOSED DEVELOPMENT ANY BE SUBJECT ROE
O OTHER
OFFICE-360-426-1803 FAX-360-427-2353 SHEET: SITE PLAN SCALE: r=W OE TMENT/AOENCY RENEW OESIGIER NOT RESPONSIBLE FOR SETBACKS UNRELATED TO
SEPTIC COMPONENTS.
. I I / /
.
/
' PROPOSED 2" SCH. 40 TRANSPORT LINE / /i
WITHIN EXISTING DRIVEWAY
I /
/ /
R900,TO NE,—, . i �// (11414
R//uC WELL —......I /
// /
MAINTAIN 50'+ TO WELLS / / 'TANKS MAY NEED TO BE
AND MAXIMIZE DISTANCE TO / / INSTALLED PRIOR TO
SHORELINE (25'+). TANKS TO PROPOSED RESIDENCE. /BE CONCRETE, COATED W/ ______
WATER PROOF BARRIER AND // / i/
TESTED FOR LEAKS PER i / ,,--
WAIVER MITIGATION. / / . /
i
/ i i
/ / /
PROPOSED TANKS /
/i / \ \ O EXISTING
O \ \_77- WELL
0 �. \ \
0 ' - ::
/ ' ` C/O \
---- i \Nit Nr)/
\ .0 \ � EXISTING TANK & DF
/
__________......i.s..
�2� TO BE PUMPED AND
��, ABANDONED
PROPOSED � /
RESIDENCE & GARAGE \--..-... /
�
♦ ♦ W/ DOWNSLOPE DECK \ EXISTING CABIN
TO BE REMOVED / /
�
/ ��
APPROX. OHWM %�l '-'�
♦ / r � �•�•• � vl•,r�l
•
i .
CASE INLET ♦ ; u�xiou°IS PA
TM ... T
, ...,_ lArsclpfaftmc,1 •
I YY1:1
AN ASBUILTI INSTALL SIGNOFF FEE WILL
BE CHARGED AT TIME OF INSTALLATION
PIONEER. DIGGING, INC.
CUSTOMER: MARY TRAMS TEST HOLE I: TEST IiJLE 2: TEST HOLE 3:
PARCEL# 22023-49 00010 0-48 0-36 I co,r. COMP. a(I&I (.I:.
SEPTIC DESIGNS ADDRESS: 920 E MAPLES RD ItC'C I S I C)48 ROOTS TO 36 30+MO1.1.
BEN
I , DESIGNER: AL L PAYSSE DRICL)J THIS IS NOT A SURVEY.REFERENCES INCLUDE'APPLICANT/COUNTY PROVIDED
3083 E MASONf3EN�.�'RD. GR.p I C IFt�.WA(� S IE .EX PLATS OR SURVEYS.FIELD MEASUREMENTS AND COUNTY GIS DESIGN INTENDED FOR SEPTIC
_ �(�, PURPOSES ONLY. PROPOSED DEVELOPMENT NAY SE SUBJECT TO OTI€R
OITIC.E-360-426.1803 FAX-360-427-2353 SHEET: SITE PLAN(2) SCALE 1"=2 DEPARTMENTIAGENCY REVIEW DESIGIER NOT RESPONSIBLE FOR SETBACKS UNRELATEDTO
SEPTIC COMPONENTS