HomeMy WebLinkAboutWAI2025-00068 - WAI Health Waiver - 12/30/2025 •
/ `, ,, \e`'� 415 N.6th STREET,SHELTON WA 98584
/An MASON COUNTY SHELTON:360-427-9670,ext 400
1.4 114 • '11 COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
i ELMA:360-482-5269,ext.400
I Building,Planning,Environmental Health,Community Health
FAX:360-427-7798
Application for Waiver or Appeal
Amount Paid' Receipt Number: Z07S ow-5-1
WAI7,C- 0006
Instructions:
1. Complete Parts 1 and 2. No determination can be made until these part are fully completed.
2. Fees may be billed for waivers and appeals, based on the Environment Health Fee Schedule.
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant & Parcel Information
Name of Applicant Zo,tk.A\ le 5uScv Zee\o o-"•v• Telephons?.(Z— 7'1 t' -5°1 2.9-
Mailing Address 16 VU O(1,..3.,,q-0 ClS _
City .-cOr�A-3,(&. State 1,-t`l- Zip 9 b
Parcel No. 2 Z 0 Z d
Site Address IN -Cu,vVro \A" V-S Q-
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
Class B Reduce Vertical Separation 0 Food Sanitation Requirements
❑ Building Permit Review Policies 0 Group B Water System Regulations
❑ Location, WAC 246-272A-0210 O Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 O Enforcement Timelines
❑ Mason County Onsite Standards O Departmental Determinations
❑ Contractor Certification Requirements O Other
(Installer, Pumper, O&M Specialists)
Description of Waiver/Appeal (include justification, additional material may be attached.
REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY PRESSURE OSS,--)
CLASS B WAIVER CHECKLIST
RECORDED DECLARATION OF ATTENUATION ZONE
Applicant Signature: Date: ti--Z b2
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)
❑ Appeal siWaiver ❑ None required ❑ Class A ea/Class B ❑ 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 O Health Officer
❑ Pollution Control hearing Board O Public Heath Director
❑ Certified Contractor Review Board i Environme ital Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN)
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZOVE(AFN 1./1;74 ) t&
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: k-D\QAP(6Y171 Date»l30
PART 4: Determination of the Hearing Official
t 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:
O 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 tl^e following findings and
conditions:
Health Official Signature: Date: /1--/ v/ a
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
,--( V)
MASON COUNTY PUBLIC HEALTH
COMMUNITY SERVICES
Bullring,Plan,g,Environmental Health,CcmmueRyHeefth CLASS B WAIVER WORKSHEET
,,,,,,-,4-',..;ILL.
415 N.6TH STREET,BLDG 8,SHELTON WA 96584 (State and Local waiver forms required)
SHELTON:360-427-9670,EXT.400- BELFAIR:360-275-4467,EXT.400
ELM&360-482-5269,EXT.400 - FAX 360-427-7798
APPUCANT NAME ilk-L.k1.\ Jr- .54.156...„,` ( `22I/1 7...,,,,,,,r11,,,,,h WANERPEAMRNUMIER WAI
MAIUNG ADDRESS' I1_d` I �w Wtl Sx mil.% C t .. /y y
QTY �f].-Y(\.ayy C".-
0 STATE i", op 1 O 5 cJ o
SITE ADDRESS �l V ` V\I C.- ati4 a.• 1-si,v<S el_ Qne Tla.k-.-ki A
TAX PARCSL NUMBER Z Z l 1 - 7-2.," ei G 0 Z V PROPOSED DRAINRE DTYPE .CONVENTIONAL GRAVITY M{CONVEN7IONAL PRESSURE
1.SOIL SERIES: 5.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_............._.........»._.21 .r Greater than 12°_._.»._.,_._.»...._. . ._.__. . . .».. 0
Harstine Gravelly Sandy Loam.._. . ._....„. ._.... .... 0 0 Greater than 18"
El-
....Hoodsport Gravelly Sandy Loam ........................ El -Determined by:
Shelton Gravelly Sandy Loam_.......---........»...._.....❑ 0 Depth to hardpan._....„......_....... . VI
Sinclair Gravelly Sandy Loam....„.......„.........„.........._..0 0 Depth to mottling........_.».......».»._...»....„...._.......__. ❑ 0
Other ...._.__❑ 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 _ -Evidence of seasonal water table:
LoamySand» 0 0 a Yes.»._...............»....»......,.......»....»...,............................... ❑ 0 rr,
SandyLoam. ................_...._......®' 15 a ...»..._.„.»...».».».»...............»....»._......
Percent Gravel: a -Curtain Drain required: p
-Less than or equal to 35%....._.__....».„._._.»._._... fir 21" aYes._.__..._ .__.„__» .. ._. .»._.»„.»._.„_. ._...._... ❑ c
-Greater than 35%_............_.„............».......„............„.0 0 $ No._._...._. ...._.__...._...... .». ...„..........„.... ........._.......... 3
3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: ?,
c
Soils must be moderately well drained to well drained. CO Primary Drainfield must maintain 200'from down-grad{- to
ent marine shorelines,surface waters,and wells. O
Well Drained..__._.„.__...._._.„„...„. . ._._._.__. . .__ ❑ 0
' t
Moderately Well Drained...».__.»».._._._._._. ._._W. IR 21 -Are Increased horizontal setbacks met:
Other ».... .».. ❑ 0 Yes„....»...».».... .... .... .._._. ._. ._.... ..._............. ....»»..
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%.._ ._._.„.„.„.„....»».».......».... . . . . . ._ ❑ ❑ -Is there 50 ft or greater between the down
3%to 15%i..,. . . .». .»._„. . .» . ._. ... ._ .».... .. gradient side of primary drainfield and
property bounds
Greater than 30%.»„._._._.». . .__»....»...._._»»..__._. 0 0 Yes_ _ ._ .__.__.__.__._.__._.__.__._.„ .__„ _.
The 50 foot horizontal attenuation zone Is required to be recorded on the deed of the property as unbuildable �� ra
prior to design approval The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: fj "l
parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recording:
TH1S FORM MAYBE SCANNED AND AVAILABLE FOR RUNIC VIEW ON THE MASON COUNTYWEBST1E updated 3/2/2017
ti r
Granting Waivers from State On-Site Sewage System Regulations Cha Iter 246-272A WAC
Effective Date: July 1,2007 Revised Ap+.12017
On-Site Sewage Systems (Chapter 246-27 A WAC)
Request for Waiver from State Regul. ions
Section I. I (completed by applicant)
Name: (1) c?....s \l Local He. th Department/District (2)
ir 5(b 5(bey, 7„e p vn a-•r (see instructions)
Address:
\V\ N D- sN)a, L
Telephone: (Zip dye
Signature:
Property'dent' tion. (3) kte, '2.2.3 7 - 2 2 ^ g ouzo
Section II. (completed by applicant)
WAC Number. (4) r
RequiPme_�__n_r (.5 , : • Aught: (6)
246-272A— -- -- --
0230 24" OF V/S FOR PRESSURE :) 12" O' V/S FOR PRESSURE OSS
Subsection: TABLE VI _ _. .. .... -
Justification(mitigation measures to be provided): (7) COMPLETED CLASS B WAIVE' CHECKLIST ATTACHED,
(OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATIS+N OF COVENANT FOR ATTN.
ZONE (AFN:
Section III. (completed by health officer)
Review Criteria: (8) Mitigation Measures(in a Nihon to those proposed): (9)
Comments/Conditions: (10)
Type of Waiver: (11) [ ] Class A p4Class B ( ]Class C—Request DOH review •efore granting? Yes No
Neighbor Notification: (12) Required? Yes_ No_ If needed, are agreements, easet,ents, etc.properly filed? Yes No
Section IV. (completed by health office')
This Request For Waiver From State Regulations has been reviewed according to the provisio of Chapter 246-272A WAC On-Site
Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or -.wired,have been evaluated for their ability
to provide public health protection at least equal to that provided by this chapter WAC.
[ ] Denied [j].Approved/Granted—Subject to all -omments,conditions and quirements noted in Sections II and III.
Local Health Officer (13) Dati: G ® �'
DOH 337-021
Lounty stamp
Tah4 Mason County Partial Approval. See notes on Page 3
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Wetland A ) • 7178 Windflower PL NW
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' • Applicant Info:
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Proposed Well I i !� LP G\�s 101 NE Dewatto Hills Rd
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LEGEND Datum NAD83 `� ,"!
- Bench Mark cI 142' 9' el 412' `''
soil log Page ``7.>
— Well
— Property Line
-••- Power Line North
--- Water line Scale
I
1" = 200'
Not A Survey 0 O
Figure 1. Site Map October 30, 2025
Mason County Partial Approval. See notes on Page 3
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