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HomeMy WebLinkAboutWAI2025-00063 - SWG Application - 11/24/2025 I MASON CO(jj Public Health Always working for a safer i healthier Mason County 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 ECEVE1 Amount Paid: It 30I� Q J AUG 2 g 2025 Receipt Number: p1Co.4.5 r 041.30a. Instructions U.)IAI `dca5 - OO (03 Y UL By 1. Complete Parts I 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 JAMES PETERSON Telephone 2538205950 Mailing Address of Applicant 4802 THOMPSON LN SE City OLYMPIA State WA Zip 98513 12-digit Tax Parcel No. 2 2 1 0 5 -- 5 1 -- 0 0 0 8 7 Site Address 3070 E MASON LAKE DR W, GRAPEVIEW, WA 98546 Subdivision Name and Lot MADINGS SUNNY SHORE ADD #3 TR 87 PART 2: Nature of Waiver/Appeal ❑ Class B Reduction in Vertical Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies 0 Group B Water System Regulations © 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 ❑ Contractor Certification Requirements ❑ Other (Installer,Pumper,O&M Specialists) Description of Waiver/Appeal(include justification,additional material may be attached.): REDUCED SETBACK BETWEEN BUILDING SEWER AND INDIVIDUAL WELL REDUCED SETBACK BETWEEN SEPTIC TANK AND PUMP TANK AND INDIVIDUAL WELL (SEE ATTACHED FOR JUSTIFICATION) Applicant Signature: Date: 8/29/25 J:\EH Forms\Waiver-Appeal Mason County Local Revised 12/1/15 Page 1 of 2 s PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑ Appeal ❑Siver ❑ None required 1.tClass A o Class B ❑ Class C 2. Identification of Specific Code/Standard/Determination(include date of determination or latest Code/Standard revision) 3. Nature of Appeal: '7 +1L U&IL t-O vi t 1( 6 4 5e� C -rote.) � -�� tp, P-k 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board 0 Environmental Health Manager 5. Mitigating Factors: (iQG R h4 ,) 4-0 a. 15( 15( (E04- 5,V) Avitacket 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: V V Date: PART 4: Determination f the Hearing Official f¢ - 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: HearingOfficial Signature: Date: /1 LY/21 / J:\EH Forms\Waiver-Appeal Mason County Local Revised 12/1/15 Page 2 of 2 NOTES REGARDING WAIVER REQUIREMENTS PER WAC 4"BUILDING SEWER REQUIRMENTS 246-272A- Building sewer,collection,non- Down to 25 feet 1)Extra protection of integrity of line la)Line installed in a casing of at least Schedule 40 PVC pipe within 50 0210(1) pressure non-perforated within 50 feet of well feet of well.Transport line uniformly supported by pressure-grouting Table IV distribution line 50 feet from annular space with sand-cement grout or bentonite,or casing spacers non-public well or suction line or skids installed consistent with AWWA PVC Pipe Design and Installation Manual M23. lb)Underground installation of line consistent with ASTM D 2321. 2)Performance testing of line 2a)Line leakage test consistent with ASTM F 1417 or exfiltration test consistent with WSDOT 7-17.3(2)B. 3)Determination of any existing 3a)Notify the well owner of the proposed encroachment if there are no covenants or easements for maintaining existing covenants or easements establishing a control area. a sanitary control area TANK REQUIREMENTS 246-272A- Sewage tank 50 Down to 25 feet 1)Extra protection of integrity of tank la)Waterproof surface barrier applied to concrete tank consistent with Manual of )210(1) feet from non- and joints Concrete Practice ACI 515.1R.Flexible rubber boots or compression seals meeting ASTM C fable IV public well or 1644,or flexible couplings meeting ASTM C 1173 used for inlet and outlet connections to suction line provide flexibility in case of tank settlement while still maintaining a watertight seal. 2)Performance testing of tank 2a)Concrete tank tested for water-tightness consistent with ASTM C 1227. 3)Accessibility of tank for ease of 3a)Access openings at or above finished grade with lockable lids or secured to prevent operation and maintenance unauthorized entry. 4)Determination of any existing 4a)Notification of proposed encroachment to the well owner if there are no existing covenants or easements for covenants or easements establishing a control area. maintaining a sanitary control area IA 7/3/25 0 — . 11 iQ.a` ►1 '">kt Ji •1 T• DtGw,2 .4 i-'•' ADAM J.HUNTER 11