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Home My WebLink AboutWAI2025-00047 - WAI Health Waiver - 6/23/2025 rLgt,4'41,P MASON COUNTY J � 1) COMMUNITY SERVICES dy 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 El VIS03§tprt74-20p--\FAX (360)427-7787 .I ' ! , Application for Waiver/Appeal JUN 2 3 2025 1 Amount Paid: D 3045 Receipt Number: 2026 By Instructions U.Jµ'c�i 20Z'D - Gci3y-1 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 BRAD ANDERSON Telephone Mailing Address of Applicant 2420 BOULDERSTONE CT City POULSBO State WA Zip 98370 12-digit Tax Parcel No. 2 2 1 0 5 -__ 5 1 __- 0 0 0 5 7 Site Address XXXX MASON LAKE DRIVE WEST, GRAPEVIEW Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements O Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) ❑ Separation 0 Food Sanitation Requirements 0, Building Permit Review Policies 0 Group B Water System Regulations Location, WAC 246-272A-0210 0 Water Adequacy Requirements O Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations ❑ Other Description of Waiver/Appeal (include justification, additional material may be attached.): CLASS A WAIVER-REDUCE SETBACK FROM WELL TO TRANSPORT LINE FROM 50FT TO 25FT MEETS ALL CLASS A MITIGATION REQUIREMENTS(DBL SLEEVED. TESTED FOR LEAKS. NOTIFICATION) Applicant Signature0 /,a4 J:\EH Forms\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 1 of2 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) Appeal /Waiver None required .Class A Class B o Class C 2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/ Standard revision) W RC. ZLI6- MO •d tiO 3. Nature of Appeal: Rcdvice mt1 mr,w, hor,'1o04a f .5eparoPori heivePm non-pub!tc cilobxi►i Weir 1 I t S T c u4- (� C w /O'c f ?to not /e5$ Imo/ 7S t f_ P{ RO P P 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board ' Environmental Health Manager 5. Mitigating Factors: mt�lt Mitigating Mef 'mon1 of '2e i -�7e4 11l11• . - T►rvlo tote -io l'$la((ed ?V? c S , item SO c'l of W I rrc lSp i¢- it- 1-0 J6* GCSfcd.1 (iel( ()vil '# fa bpi n0 0-• 41( • 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: 47-- Date: 7/5/ ?o2f 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: gle Date: Y'/,,f 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. I (completed by applicant) Name: (1) BRAD ANDERSON Local Health Department/District (2) (see instructions) Address: 2420 BOULDERSTONE CT M000 COM / l POULSBO, WA 98370 Telephone: ( ) Si re. a 4,44 jr) Property Identificati n: (3) 221 -51-00057, XXXX MASON LAKE DRIVE WEST Section II. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A— 0210 50' WELL TO T - LINE 25'+ WELL TO T-LINE Subsection: TABLE IV Justification(mitigation measures to be provided): (7) WELL OWNERS NOTIFICATION (SEE ATTACHED), LINE WILL BE SCH. 40 & DBL. SLEEVED IN HDPE BORE PIPING, TESTING FOR LEAKS AT TIME OF INSTALLATION. SYSTEM MEETS TLN, UTILIZING LOT SIZE REDUCTION PER SUBSECTION -0320 Section III. I (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (10) 111e05 ati55 I cipp(ovec/ miii)c4'st"l me4SGrtS. Type of Waiver: (11) k Class A [ ]Class B [ ]Class C—Request DOH review before granting? Yes_ `Noo X Neighbor Notification: (12) Required? YesX No If needed, are agreements, easements, etc.properly filed? Yes JC 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 Sections 11 and Ill. Local Health Officer (13) Date: DOH 337-021 Page 26 of 32 Pioneer Digging Inc. 3083 E. Mason Benson Rd. Grapeview, WA 98546 DANIELS, MICHAEL J 6/20/2025 12234 SE 57TH#263 BELLEVUE WA 98006 To whom it may concern: I am a Septic Designer working with your neighbors on Mason Lake,Brad Anderson, on a new septic design. This letter is to inform you that the Andersons have made application for a waiver to locate their septic transport line closer than the standard setback of 50 ft. from the well located on your parcel, but not closer than 25ft. Washington State allows these setback reductions provided it meets specific mitigation measures which include sleeving and testing the line for. leaks. We are required to notify you of this application as part of the review process. If you have any questions or concerns you may contact myself or Mason County Health Department at the ' numbers below. Thank you for your time. Pioneer Digging Inc. - 360-426-1803 —Robert H. Paysse/Designer Mason County ealth Department- 360-427-9670 - Ext. 400 ekr . • 0:y' stoost� � D.BERT H R YSSE �i 1i i>iiy..iYiii. EXPIRES U.S. Postal Service". • . CERTIFIED MAIL' RECEIPT Domestic Mail Only art ra For delivery information,visit our website at tvirv.usps.com'. Q•' •t4f: r J Certified Mall Fee ?= ( ' Extra Services&Fees(cheek box add fee K W)f W9t1 U t~s a t rlu ❑Return Receipt(hardoopy) S ❑Return Receipt(electronic) S "•` I' y Postm N5 CI ❑eafened Mall Restricted Delivery S :!'I,Ili I �. A is LV6� { • N ['Adult Signature Required $ . tcrl.r �;'t ,,t ' rU ❑Adult Signature Restricted Delivery Ln Postage ' !'. , - _ i' .f' ' $ f t� ;; ,,,.. r—'R Tout Postage and Fees �•= San To $free and• o., r cox No. 6 s - , a a r3•+ai •,• . .A� • 200 • PS Form 3800,Januar 2023 as%7530-02 303A047 See Reverse for Instructions