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Home My WebLink AboutWAI2026-00006 - WAI Health Waiver - 1/12/2026 - 415 N.6th STREET,SHELTON WA 98584 SHELTON:360-427-9670,ext 400 7 MASON COUNTY BELFAIR:360-275-4467,ext.400 COMMUNITY SERVICES s. , Building,Planning,Environmental Health,Community Health Tiq rvii6 A lication for Waiver or Appeal "' JAN 12 p pP 2025 Amount Paid: O Receipt Number: € (:)D,'Q O0 By WAl 2 O01 (p - DO 0013 Le Please note,all approved Onsite Waivers have the same expiration date as their OSS Permits. Instructions: 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 Information Name of Applicant \rc `r c �C L Telephon ((r, k-57\ � Mailing Address \\C)O COX C�M\� �J City \� O'CNC\c'f:A\-- State � �l ZipC : 4/0 Parcel No. — — l J Site Address 5\ \>\-cw Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Onsite: Class A Waiver O Food Sanitation Requirements Onsite: Class B Waiver O Group B Water System Regulations ❑ Onsite: Class C Waiver O Water Adequacy Requirements ❑ Onsite: Location,WAC246-272A-0210 O Building Permit: EH Review Policies ❑ Onsite: Holding Tank,WAC246-272A- O Appeal:Enforcement Timelines 0240 O Appeal:Departmental Determinations ❑ Onsite: Contractor Certification O Other Requirements Description of Waiver/Appeal (include justification, additional material may be attached.): Reduce Vertical Separation for Conventional Gravity or-Rressure OSS Class B Waiver Checklist Recorded Declaration of Attenuation Zone Applicant Signature. I\ Date: \ Revised 9/29/2025 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 s/Waiver None required -I Class A s/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 Health Director ❑ Certified Contractor Review Board l2' Environmental Health Manager 5. Mitigating Factors: CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN LZ b ) 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. ` C77117-6 Staff Signature: Date: PART 4: Determination of the Hearing Official e. 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 the following findings and conditions: Health Official Signature: Date: I/1-O- Revised 9/29/2025 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 MASON COUNTY MASON COUNTY PUBLIC HEALTH COMMUNITY SERVICES _ Building Planning,Environmental Health,Community Health CLASS B WAIVER WORKSHEET 415 N.6TH STREET,BLDG 6,SHELTON WA 96584 (State and Local waiver forms required) SHELTON:360.427.0670,EXT.400-BELFAIR:380-275-4467,EXT.400 APPUCANT NAME Ce4.\\m l f \ \^`r\c....\---,,,c\ -,--;\4:,$)` -�.� IC WAIVER PERMIT NUMBER WAI\, :MAILING ADDRESS \ lC Z Co, l�C��h 1-31 �'.,] 1 - J CTT1' \ STATE I V ZIP ("IP- srIEADDRESS �_ ''+\ \-)N--�\,'� crrr � TAX PARCEL NUMBER 'C _J ` \ 1\` PROPOSED DRAINFIELD TYPE )4 CONVENTIONAL GRAVITY CONVENTIONAL 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 O O Greater than 12" O O Harstine Gravelly Sandy Loam Greater than 18" j Hoodsport Gravelly Sandy Loam O -Determined by: Shelton Gravelly Sandy Loam O O Depth to hardpan V Er Sinclair Gravelly Sandy Loam O O Depth to mottling O O Other ...........O O Both O O 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 O O 2 : -Evidence of seasonal water table: Loamy Sand O O 2 Yes O O Sandy Loam y No Percent Gravel: ra -Curtain Drain required: -Less than or equal to 35% IA a Yes O O V. • -Greater than 35% o 3 No 'El r rb 3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: ft, Soils must be moderately well drained to well drained. C3.:. Primary Drainfield must maintain 200'from down-gradi Z ` ent marine shorelines,surface waters,and wells. 'C Well Drained O O •.< . Moderately Well Drained lit -Are increased horizontal setbacks met: Other O Yes ,ffr No O ❑ 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% O i -Is there S0 ft or greater between the down 3%to 15% Et. gradient side of primary drainfield and 16%to 30% O property boundary: r, Greater than 30% O \ O Yes Ibt gr No ❑ The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable 2� Q` , prior to design approval The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: 15G 4 V y parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recording: THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE. updated 3/2/2017 On-Site Sewage Systems (Chapter 246-272A WAC) Washington State Departmental Request for Waiver from State Regulations a r HEALTH Section i. (Completed by applicant) Name: (1) Local Health Jurisdiction Received (2) �� cC' See instructions) Address: C-0\\Nqic NiaSon Counfy c? ,‘C ‘C i\O\ .'1?)9•JU Teleoone: Signarur Property Identifi (3) IC _ \ Section II. I (Completed by applicant) WAC Number:(4) WAC Requirement: (5) Waiver Sought: (6) 246-272A- 0230 24"of V/S for Pressure,(or) 'it—Of-V/8 for PrC33urC OSC (or) Subsection: Table VI 36"of V/S for Gravity _ 18"of V/S for Gravity OSS Justification(Proposed mitigation measures): (7) Completed Class B Waiver Checklist Attached,(Outlining Additional Requirements Met). Recorded_ Declaration of Covenant for ATTN. Zo ne (AFN: '� � � ) �� y Section Ill. I(Completed by local health officer) Review Criteria: (8) Additional Mitigation Measures:(9) ----------------- Comments/Conditions:(10) ee CTass B alver Woiksheef- Type of Waiver: (11) Class A n Class B []Class C— Request DOH review before granting? Yes[]No Neighbor Notification: (12) Required?YesnNo n If needed, are agreements,easements,etc.filed? Yes Non 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 /t Approved/Granted— bject to all comments,conditions and requirements noted i ections II and Ill. Local Health Officer(13) Date: /Z-/ 2-( I'v DOH 337-175 February 2024 1 Mason County WA GIS Web Map t ( .„... ... V 15 • 1.. �1 • T`J u o r; ti 0 VI 11 5, o CD b( .. fJ r, / 1 - / • 1 c U `r , \ `t h -,/ S sN ^ /;/.-./.. -0 OPT► It r •� ��•. ...,_ _71., , i c:7 ....,,„i. 1 1 ' O 0 p n U )h 0 C ci iz, D ri ,,,), ) ....>,..;,„... . ,,,,::\ 0 1.,:, ,....) ':''--:\ vk ' ' 1..'')'.. / (---- '''n___ : c. 1/28/2026, 8:20:05 AM 1:3,073 \� \ Th\.\ --K-- 0 0.03 0.05 0.1 mi County Boundary i , ' , + ' , , 1 0 0.04 0.08 0.16 km -' No Filled j \\ ca( — ( M 3 :----Cc3,\Q t El Tax Parcels (Zoom in to 1:30,000) Sow s:East,HERE.Garrnin, USGS, Intermap, INCREMENT P. NRCan. Esti Japan, MEfI, Earl China (Hong Kong), Esri Korea. Esn (Thailand), Contours 5 ft NGCC,(c)OpenStreefMap contributors,and the GIS User Community Mason County WA GIS Web Map Application Mason County disclaims accuracy,reliability,or timeliness of website info,not liable for losses from reliance on it.https/twww_masoncountywa gov/disclaimer.php