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Home My WebLink AboutWAI2025-00037 - WAI Health Waiver - 5/21/2025 43. " \ 415 N.6th STREET,SHELTON WA 98584 TAT• •\ MASON COUNTY SHELTON:360-427-9670, ext 400 (. -:; :. s' COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 ELMA:360-482-5269,ext.400 Building,Planning,Environmental Health,Community Health FAX:360-427-7798 Application for Waiver or Appeal Amount Paid: V3� Receipt Number: .0 „�-(�o��y 14)‘ 1EC WAI aoa9- ()0 0- MAY a.\ 2025 Instructions: By 1. Complete Parts 1 and 2. No determination can be made until these parts are full com let 1.1 2. Fees may be billed for waivers and appeals, based on the Environmental Health Fee Sch I.:3. Submit completed application with attachments to Mason County Public Health for review. MA :�. 2025 PART 1. Applicant & Parcel Information By 1. ---- -- Name of Applicant �' \cx\--v,n ' Mailing Address `;!•�.`Cti�� \ � 1\ City �r'\P (�C� State V, Zip Parcel No. \ � Cn — — C) ( ?) 0 Site Address \ C7�� C � c74-C 'A\� ---D6ti'1 .q:\>\S Subdivision Name and Lot PART 2: Nature of Waiver/Appeal EY Class B Reduce Vertical Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies 0 Group B Water System Regulations O Location,WAC 246-272A-0210 0 Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations O Contractor Certification Requirements 0 Other (Installer, Pumper, O&M Specialists) Description of Waiver/Appeal (include justification, additional material may be attached.): REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY OR PRESSURE OSS CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE • Applicant Signature: �` • Date: * j PP 9 Revised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 PART 3: .Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver (if applicable) i Appeal i/Waiver -_: None required Class A v'Class B ,.H Class C 2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/ Standard revision): WAC246-272A-0230, TABLE VI 3. Nature of Appeal: REDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL GRAVITY OR PRESSURE OSS. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board ' Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN 42?Xi (i 9 ) Aj) L,)ti(b 1)611J(1.610r 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local polio has been submitted. ll ( `� Staff Signature: - ,i -\)s\/ Date: 6 / a5 PART 4: Determination of the Hearing Official 6- 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: fC" Date: c i?/Zi Revised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 MASON COUNTY COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH Building,Planning,Environmental Health,Community Health CLASS B WAIVER WORKSHEET 415 N.6TH STREET,BLDO 8,SHELTON WA 98584 (State and Local waiver forms required) SHELTON:360-427-9670,EXT.400- BELFAIR:360-275-4467,EXT.400 ELMA:360-482-5269,EXT.400 -FAX:360-427-7798 APPLICANT NAME nfi,-j�,,\`� ��j � ` \ , WAIVER PERMIT NUMBER WAI MAILING ADDRESS �f\l� ` C \ \\ \ \ \'"N \C 1\. Skk CITY • -� � rr • STATE \,V ZIP'a )' } SITE ADDRESS �C ��`� ` Ca _ \k\ \ 11 C A TAX PARCEL NUMBER \C �_, \��., N\\-30 PROPOSED DRAINFIELD TYPE CONVENTONAL GRAVITY CONVENTIONAL PRESSURE 1.SOIL SERIES: S.VERTICAL SEPARATION: The soil series must be Alderwood,Harstine,Hoodsport, Up-slope vertical separation must be greater than 18" Shelton,or Sinclair Gravelly Sandy Loam. for gravity and greater than 12"for pressure. Alderwood Gravelly Sandy Loam 0 ❑ Greater than 12" 0 Harstine Gravelly Sandy Loam Z. Greater than 18" . Hoodsport Gravelly Sandy Loam 0 /❑ -Determined by: Shelton Gravelly Sandy Loam 0 ❑ Depth to hardpan 0 0 Sinclair Gravelly Sandy Loam 0 0 Depth to mottling 0 0 Other 0 0 Both 0 ❑ 2.SOIL TYPE: 6.WATER TABLE LEVEL: Soil types must be Medium Sand,Loamy Sand,or Sandy If test holes show evidence of a seasonal water table Loam.Gravel percent must be less than or equal to 35%. above restrictive layer,a curtain drain may be required Medium Sand 0 0 Z -Evidence of seasonal water table: Loamy Sand 0 ❑ q Yes 0 0 n Sandy Loam No 121 �j Percent Gravel: �` -Curtain Drain required: ! -Less than or equal to 35% V h� Yes 0 ❑ -Greater than 35% 0 in ro No : 3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: Solis must be moderately well drained to welt drained. p, Primary Drainfield must maintain 200'from down-gradi ft - 3 ent marine shorelines,surface waters,and wells. • 0 Well Drained 0 0 Moderately Well Drained 14 0 -Are increased horizontal setbacks met: Other 0 ❑ Yes 'Er 232.. No ❑ ❑ 4. DRAINFIELD SLOPE: 8. ATTENUATION ZONE •Slopes must be between 3%to 30%. Gravity is only allowed on slopes from 3%to 15%. A 50 foot horizontal attenuation zone is required Pressure is allowed on 3%to 30%. down-gradient of the primary drainfield. Less than 3% 0 -Is there 50 ft or greater between the down 3%to 15% gradient side of primary drat field and - 16%to 30% 0 property boundary �, Greater than 30% ❑ 0 Yes yyr ❑ No / 0 The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as un ildable I prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks, tios, AFN: 222)1 Y parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Pr of Recordinn THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE updated 3/2/2017 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 Isection1.; , (completed by applicant) Name: (—,„dt 1) Local.Health Departmental District (2) \ ,_ -\., ,,<\— J (see.instructions. ._. _ ,,-- ,. \,-------- .___. NTh \.t \ cN. \---1-\ , ______. ______. Telephone: ($ ) \ ` Signature: �.N �� 'l\—� � r Property Identification: (3 .. \)()\\--(--'_..('\ -- 4, C\C Section XI.. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A— 0230 ) 12" F OR) Subsection: TABLE VI 36" OF V/S FOR GRAVITY 18" OF V/S FOR GRAVITY OSS 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: ) Section In (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) it ,WW toe, ,b t ld ‘Kfcr- _ tv Attic( . ►t cam' , by .e p.i r v /49r, P1,( ,22StC1 Comments/Conditions: (10) Type of Waiver: (Il) [ ]Class A j'_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/Grante —Subj to all comments,conditions and requirements oted i Sections II and III. Local Health Officer (13) Date: p7 2f DOH 337-021