HomeMy WebLinkAboutWAI2025-00005 - WAI Health Waiver - 1/27/2025 r
415 N.6d'STREET,SHELTON WA 98584
MASON COUNTY
SHELTON:360-427-9670,e#400
COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
g,ady,gpy,no-,y,�He^C MWt R®IM ELMA:360-482-5269,ext.400
FAX:360-427-7798
Application for Waiver or Appeal D O E M D
Amount Pak: -3565 Receipt Number: yr D
1AN 25
WAI ZazS _ 00005
Instructions: BY
1. Complete Parts 1.and 2.No determination can be madEuntil these parts are fully completed.
2. .Fees may be billed for waivers and appeals,based on nvironmental Health Fee:Schedule.
3. Submit completed application with attachments to Masunty Public Health for review:..
PART 1. Applicant & Parcel Information LL�� //
Name of Applicant ss OcY'i\a�l Telephon `J' O 2
Mailing Address 9 f W > \ ^� /
City 1— h State VAS _TzPac--)!
Parcel No.
Site Address
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
d Class B Reduce Vertical Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements ❑ Other
(Installer, Pumper, O&M Specialists)
Description of Waiver/Appeal(include justification, additional material may be attached.):
REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY
CLASS B WAIVER CHECKLIST
RECORDED DECLARATION OF ATTENUATION ZONE F • Z 77. Z r
Applicant Signature: \ >`' '1 ` Date:
This form may be scanned and available for public Wald on the Mason County Web site.te.ae4 enlrzal7
Paac 1 of2
PART 3: Public Health Evaluation (Staff Use Only)
t. Type of Determination Required: Type of Onshe Waiver(if applicable)
❑Appeal V Waiver ❑ None required ❑ Class A 6/Class B ❑ Class C
2. Identification of Specific Code/Standard/Determination (include date of determination or
latest Code/Standard revision): WAC246272A-0230,TABLE VI
3. Nature of Appeal:
REDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL GRAVITY M
1 RE68UAE OSS.
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board GI` Environmental Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST MEETS ADDITIONAL REQUIREMENTS OUTLINED WrrHIN
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE(AFN ZZ Z I Z LI I
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the
state and local policy has b submitted. 7
Staff Signature: Date: Z 10 5
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: Date:
Revved S/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 2,,f 2
MASON COUNTY MASON COUNTY PUBLIC HEALTH
0 COMMUNTIY SERVICES
CLASS B WAIVER WORKSHEET
als e.am sraeE[Ema,eNELIaN WAvava (State and Local waiver forms required)
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1.SOIL SERIES: 5.VERTICAL SEPARATION:
Thesoll series mun beAWerwood,NarstiiE,Hoodsporr. - Up-dopevvityaneparatvdiarlbe greats Man ta'
SheRm,or SlnckVGrsvelly Sally Loam, fargrevnyarM peaterthan 13"for pressure.
Aldervmod GraveRysandylwm..______.___❑ ❑ Greaterthen l2'.___.._______._.__._.. ❑ 0
Harstine Gravelly Sandy Loam__.______.__ ❑ ❑ Greater than l8'.._..__
Houdsport Gravelly Sandy L.oaln..............— ❑ ❑ -Determined by:
Shelton Gravelly Sandy Loam_._..____._.___.❑ ❑ Depth to hardpan ❑ ❑
Sindai ra�(Ily SandyIoam.._._ ❑ ❑ Depth to mottling._____.________ p F Other \�aM J¢ _�.gl Bmh..�._._._._.__.__�_�_______ ❑
2.SOILTYPE: 6.WATER TABLE LEVEL:
Shctypes munbeMedium Sand Loamy Sand,or Sandy HterthoksshowevM —o/a-a,.—lwa-r1A
Laam Gravel Zntmustbelm Man orequal so 35%. above reshictive byer,a NnaVn drain may be required
Medium Sand_..___._._.______..__..._� _ -Esidelwo(aeasonalwatewtablr.—�_..._.� �. .
Loamy Sand........... Elo Yes_._.......................___
Sandy Loam ❑ ❑ s No......_............_.........._........... ❑ ❑j 9
PercentGraveF. a -com"n Drain rapulrad: p..
/ m
-lass than or NMI to Ves...__..------------....___.____.__..._. ❑ ❑.o.
-Greater than 35%._.._____..__...____.❑ No_..... : 3 Y
3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS:
N
Sdk museberrvxkralely welldralmtltowels drained. O Rlmary DrNrintld must mantain]pa'/mm dawn-gratlF w0
ent madmshorellnes,surfattwaron,and wells. 7
7 S t
_ Well Drained__.__..._._....._.._._.._._.____......._---0 sFs
Other tetyWell Drained_._.�—__.___ ❑ 0 -As a Increased horizo.EfalwWacb met
Other ... .._ ❑ ❑ :- Yes_._.........__............ ..........----
No � .
4.DRAINFIELD SLOPE:
B.ATTENUATION ZONE
Slopes must be belsaeen 3%m 30 i
GreWty isanly allowed onsbpesfrom3%ta 15% A5a foot hanonlal attEwation mne is required
pressure a albwed on 3%to 3Wb, dawn9ndienl NMe primary drelnfidtl.
Less than 3%_..._.......... ❑ I❑ayaA� -Is them 50 k or greater between the doom
3%to 15%.._.�.�_.__.._...._�.�_..� pa gradient side oy primary drainfield and
❑ ❑ property boundary:
Greater than 30%_------- ❑ Yes.______ . . .. . .....
TheSOfoothorizantal menuatlon zaEls requiredroberecorded on Medeedofthepiopenyasuribulldable �/
ptorWdesignap,amid,Theattenuabomm�els Wwbeusedror Me=a lonofro %decks. Uo% AFN:M132
md{ng aRaS,V¢II NIartRfh4mm11H Slml ar seCh uses.TheomwermurtagreewaRMewcoromans, n aft µq
n{SrEIMIMVEs[MMn)uN AVNAflFFOewEIiNkW WIMEMJ.idifOLW1YNEB511E toonw "
Grramung Waivers from State On-Siw 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 L. (completed by applicant)
Name. (1) Local Health Department l Disuim (2)
u �� ..:._�1( see instructions); -_ ;. . _
Address: CC"
Telephone: -
Telephone: (1,)V)
- -_
Signature:
Propertyldentification: (3)
$eCitOII Yl. (completed by applicant)
WAC Humber: (4). . . WAC Requrenwnt: (3) Waiver Sought: (6)
246-272A— 0230 2 R) 1
subsection' TABLE VI 36"OF V/S FOR GRAVITY 18-OF V/S FOR GRAVITY OSS
Justification(mitigation areasares to be provided): (7) COMPLETED CLASS B WAIVER CHECKLIST ATTACHED,
(OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN.
ZONE AFN: tj 13 L L
SCMI06Af.: (emmpleted by healthaffi )
Review Criteria: (g) Mitigetioa Measures(m addition w thaae proposed): (9)
Comments/Conditions: 00) t LV�L
Type of Waiver: 01) ( ]Class A 0 Class,B [ ]Claw C—Request DOH review bdgm gmnfmg? Yes_ No
Neighbor Notification: (12) Required? Yea_ No 1f needed,are agreements,easements,ew.penperly filed? Yes No
SeeHon:IV. (completed by health affuer) —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 L14Approved/Granted—Subject to all omments,conditions and requirements noted in Sections D and 111.
Local Health Officer (13) Date: z/mil L7
DOH 337-021