HomeMy WebLinkAboutWAI2026-00020 - WAI Health Waiver - 3/25/2026 415 N.6th STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360-427-9670,ext 400
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: a�d Receipt Number: IV rt q
WAI ao - aooao n zl
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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 l_ S S Telephone 3 is 0-8 Z_1- ( O 3ô
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Mailing Address ('8(o Z t9Rf -( ST_ S
City O L S - fL State L' Zip ' 6 S-r
Parcel No. 3 0 Z -- `� 1 -- C) C) 0 3 0
Site Address 3 S►1✓t tL L..L..SLA)00t6 1w A`(
Subdivision Name and Lot CVlc-t 3 Q Sy�Z 1 L' (
PART 2: Nature of Waiver/Appeal
l ' Class B Reduce Vertical Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies O Group B Water System Regulations
❑ Location,WAC 246-272A-0210 O Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards O Departmental Determinations
❑ Contractor Certification Requirements ❑ 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: -23
• 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 'Waiver ❑ None required ❑ Class A '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 ❑ Health Officer
❑ Pollution Control hearing Board O 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 33Z 3'Y)
6. I have received this waiver/appeal request. It is complete and mitigation required by the
.state and local p ' y has been submitted.
Staff Signature: L ti _ Date: ' ' =2
PART 4: Determi tion of the Hearing Official
j&. 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: Date: j 1-
Rev' ed 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,BLDG 8,SHELTON WA98584 (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 a/�41.i y}}`G 3 j� ,,.� I / �^ y/�f WAIVER PERMIT NUMBER WAI
MAILING ADDRESS [J`\'V��y" y`b �'`,V L`I o- ` A
CRY STATE W6y1 ZIP Q,.
SITE ADDRESS �('• ' �S w '�
CRY
TAX PARCEL NUMBER ,O Z.►_ 4 '• V C 3 PROPOSED DRAINFIELD TYPE CONVENTIONAL GRAVITY Q'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................................ Greater than 12"................................................................
Harstine Gravelly Sandy Loam..................................... ❑ O Greater than 18"................................................................ ❑
Hoodsport Gravelly Sandy Loam................................ ❑ ❑ -Determined by:
Shelton Gravelly Sandy Loam.......................................❑ ❑ Depth to hardpan............................................................. ❑ ❑
Sinclair Gravelly Sandy Loam........................................❑ ❑ Depth to mottling.......................................................... ❑ ❑
Other ...........❑ ❑ Both.......................................................................................
2.SOILTYPE: 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.................................................................... ❑ ❑ -Evidence of seasonal water table:
LoamySand.........................................................................❑ ❑ a Yes.......................................................................................... i
SandyLoam.........................................................................Lm1 No........................................................................................... ❑
Percent Gravel: -Curtain Drain required:
-Less than or equal to 35%....................................... ❑ ❑ o m
Yes......................................................................................... ❑ U �
-Greater than 35%.........................................................❑ ❑ No..........................................................................................
3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: ;
Soils must be moderately well drained to well drained. p Primary Drainfield must maintain 20O'from down-gradi-
ent marine shorelines,surface waters,and wells.
.
WellDrained...................................................................... ❑
Moderately Well Drained -Are increased horizontal setbacks met:
Other .............. ❑ ❑ Yes..........................................................................................
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%...................................................................... ❑ ❑ -Is there 50 ft or greater between the down
3%to 15%.......................................................................... . . gradient side of primary drainfield and
16%to 30%........................................................................ ❑ ❑ property boundary:
Greaterthan 30%............................................................. ❑ ❑ Yes..........................................................................................
No.......................................................................................... ❑ ❑
The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable
prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: jf ✓✓
parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recording:
THIS FORM MAYBE 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
Section I I (completed by applicant)
Name: (1) T ` i Local Health Department/District (2)
- - ---L-.. ............ ............... see instructions1 ---- ---- ------------------------------- .......-
Address:
-----------------•• --------.............----.................... .......... .................................. ..
-----•-•--•---.........._.._.......
-------------------------------------------------......_.....-.......------------------...----------------------------------....__.............----•-......------. -----........------...._...-----------.......----...........-----------------.........---------.......------........---------.......:__.._........_._..............-----•------
Telephone: C3 Led )
Signature:
Property Identification: . Lc
--•------------------------------------- .. - . ..... __..._.
Section H. I (completed by applicant)
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
----------------------- ------------------.----------- ;._.. - ---------------------
246-272A— 0230 24" OF V/S FOR�RESSURE OR) 12" OF V/S FOR RESSU E OSS (OR)
- --------------- .
Subsection: TABLE VI 36" OF V/S FOR GRA 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 III. I (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
-----------— -----------------------------•---•--------------------------------------.......-------------------- ---------------------------...------------...------------------------------------ — .....-- D------------------------.
---------------------...... ...... ...............--. - —'e?
Comments/Conditions: (10)
Type of Waiver: (11) [ ] Class A 14Class 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 provide by this chapter WAC.
[ ] Denied 4 Approved/Granted—Subj to all comments,conditions and requirement noted in S ctions II and III.
Local Health Officer (13) Date:
DOH 337-021 Page 26 of 32