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Home My WebLink AboutWAI2024-00017 - WAI Health Waiver - 2/22/2024 415 N.6'h STREET,SHELTON WA 98584 r • iiii,r MASON COUNTY SHELTON: 360-427-9670,ext 400 .~=f COMMUNITY SERVICES BELFAIR: 360-275-4467, ext.400 \•- �-^'`✓"-- - ELMA:360-482-5269, ext.400 Building.Planning,Environmental Health.Community Hearth FAX:360-427-7798 ADolication for Waiver or Appeal Amount Paid: ' ` ` . Receipt Number: -Z - WAI ab'l`i - 060)` Fttj z Z ?IA Instructions: 1 r 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 Royal Revocable Living Trust Telephone (503) 828-9212 Mailing Address 11950 SE Idleman Rd City Happy Valley, State OR Zip 97086 Parcel No. 3 2 0 2 1 -- 5 7 -- 0 1 0 0 7 Site Address 71 E Orchard Ln, Shelton, WA 98584 Subdivision Name and Lot Shorecrest Add 2nd Replat, Blk 1, Lot 7 & Tax 235-B S 29/202 ii PART 2: Nature of Waiver/Appeal ❑ Onsite: Class A Waiver 0 Food Sanitation Requirements ❑ Onsite: Class B Waiver 0 Group B Water System Regulations ❑ Onsite: Class C Waiver 0 Water Adequacy Requirements Onsite: Location: WAC246-272A-0210 0 Building Permit: EH Review Policies ❑ Onsite: Holding Tank, WAC246-272A- ❑ Appeal:Enforcement Timelines 0240 0 Appeal: Departmental Determinations ❑ Onsite: Contractor Certification 0 Other Requirements Description of Waiver/Appeal (include justification. additional material may be attached.) Reduce setback from septic tank to shoreline from 50' down to a minimum of 25'. See Attached Mitigation. Applicant Signature: � Date: 71C5A-StaNat\-(13/1 S-e.ip fie- 4' - ear- R,i si d 8;13/2018 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 prommly PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver (if applicable) Appeal Waiver None required )lCJass A Class B Class C 2. Identification of Specific Code/ Standard/ Determination (include date of etermin tion or latest Code/ Standard revision): I-15 —'G,— Z�] ?A 0 3. Nature of Appeal: C_Q, S ice, � 1 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board SZL Environmental Health Manage al 5. Mitigating Factors: ,_ P r aw-&v, a-cc S f o� f�� 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: 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: 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: Health Official Signature: 647Date: LA 7,2.4 R, ised 8/1 3120 1 8 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 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) Pal voCpeLe LtV1N(�'('RUST _-- (see instructions - Address: 1\9 S 0 SE L l -E m A . (�D RRPP\I \IALLEv OfS 1108CD Telephone: (Co3) 8 Qg-q 2.12 ELF ets°1.' Signature:_ _ - 8r.�. Q 4- Property Identification: (3) �A�C�C� : 3 2 D 2.[- 5 _ 01007 51.koF.eGRST ADD 2 - _0 SE PLAT 61 -1/4- P\X 2_ 3 5- 8 S 2.9 ( 202. Section H. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) ` -- .(c.s 4-0 246-272A— 02.10 5 � � ‘84.r So 1e-c_ vso is s s ZS mow. 31-orr-LN^ - Subsection: S4sert-lAv�c_ Justification(mitigation measures to be provided): (7) ScAe�t � .L.o le.e_ O �'eA o S Qk 1ti _ -Soo C...-4.P40-&rc- a-91- S��a�- .( . Sre Q C- ia. - 1r". . 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 [ ]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 [.Approved/Granted—Subject to all comments,conditions and requirements noted in ections II and III. Local Health Officer (13) 4=74' Date: 12 / 2- 7 2-5, 19 Application for Waiver/Appeal Mitigation 2-20-24 Owner: Royal Revocable Living Trust Phone: (503) 828-9212 Eli Royal Mailing Address: 11950 SE Idleman Rd, Happy Valley, OR 97086 Site Address: 71 E Orchard Ln, Shelton, WA 98584 Parcel Number: 32021-57-01007 Property Description: SHORECREST ADD 2ND REPLAT BLK: 1 LOT: 7 &TAX 235-B S 29/202 1) State DOH Waiver Sought: Reduce horizontal separation between septic tank(s) and surface water from 50'to no less than 25'. a) Waterproof surface barrier applied to concrete tank consistent with Manual of Concrete Practice ACI 515.1R. Flexible rubber boots or compression seals meeting ASTM C 1644, or flexible couplings meeting ASTM C 1173 used for inlet and outlet connections to provide flexibility in case of tank settlement while still maintaining a watertight seal. An approved double-wall plastic or fiberglass tank may be used in lieu of a concrete tank. b) Concrete tank tested for water-tightness consistent with ASTM C 1227. Fiberglass tank tested for water-tightness consistent with IAPMO/ANSI Z1000-2007. c)Access openings at or above finished grade with lockable lids or secured to prevent unauthorized entry. **Note: Per Mason County records, parcel is 0.39 acres, or approximately 16,988 s.f. and exceeds minimum lot size for State Waiver eligibility of 12,500 s.f.**