HomeMy WebLinkAboutWAI2026-00055-WAIVER/APPEAL - WAI Health Waiver - 12/3/2025 P.
415 N.6th STREET,SHELTON WA 98584 SHELTON: ext 400
BELFAIR:360-275-4467,�eM 400
• Public.Health &.Human Services
Iv���lUi_h S _ ��� 3
'�®�o Application�� pp for Waiver or Appeal
Amount Paid: c O Receipt Number: can 5
WAI __ cep 66
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 r O w4J /-'tacaE. Telephone
Mailing Address 3L'7 S'G.. f1, .
City � �G ii s- State [ t#'� Zip 4 $_2..
Parcel No. S ' L c� __ J, / __ U Z
Site Address 4l 3 D rn 1 Q •Ili
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Onsite: Class A Waiver ❑ Food Sanitation Requirements
❑ Onsite: Class B Waiver ❑ Group B Water System Regulations
❑ Onsite: Class C Waiver ❑ Water Adequacy Requirements
- ' Onsite: Location,WAC246-272A-0210 ❑ Building Permit: EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- ❑ Appeal:Enforcement Timelines
0240 ❑ Appeal:Departmental Determinations
❑ Onsite: Contractor Certification Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
3 13ecf L.. o.bn 9 -.w
U
M'1,' r 11 ry
6 I'�1 .v SIC. •rc 0ir f'a w
fig
Applicant Signature: • y Date: W Z4 .
1 ) �
Revised 03/03/2026
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'Determihation Required: Type of Onsite Waiver(if applicable)
❑Appeal Waiver ❑ Class A ❑Class B ❑Class C LrJ Local
State Waiver Criteria
Number of Bedrooms:3 Nitrogen Treatment: ❑Yes No
Soil Type: 3 So r( de.Se,. Ga 11.1) Minimum Lot Size: I a.c. sq.ft.
Water Source:❑Pub c Crivate This Lot Size: G ae _ sq.ft.
Is This Lot Eligible for State Waivers: C1 'es 0 No ❑ N/A
Hearing Official:
Environmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/Standard/ Determination (include date of determination or I test
Code/Standard revision): OM sic r� s° �L„�,. TL„
3. Nature of Appeal:
Tn.,r)21 4 c 1Y!. /en i150 LJr1di ope.e.Jlt'I..,
o U rmall •r
5. Mitigating Factors:
14. r s` 3 r G a 11 o..+Jr s •e o/ c�AJ
T
e 7 ae'#t"p Tai a s/, Arat! l/w' 7LA✓ S'u 3Ihvo' r
l 4' 2e/[ . g sr d27-z rL�oa�&.#.f boo
(, n, 7 13 w rn aP® Cy.?41
6. I have received this waiver/appeal request. It is complete and mitigation required by the state 0 Uc 4_l
and local policy has been submitted.
Staff Signature: Date:
PART 4: Determination of the Hearing Official
0 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:
LFhe 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:
.laa A. i
1 /
it ' 6, a74 4c;.j w i-vin /J' e/ob J G(o/{K,
Health Official Signature: Date:
Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
Mason County OSS Installation,Report pg. it MASON COUNTY PUBLIC HEALTH
APPLICANT!PERMIT-INFORMATION
Permit Number. SWG Parcel# �"! -•� pp�_,p
Applicant Name f ilS Subdivisl n(Name/Div/Block/Lot)Applicant Address '7 S J 1, S . 32%
City,State,Zip i11 9 I'3p staller Name A/b '
Site Address # V/4., Designer Name 6t/ '.s X40279 C+-W-'
INSTALLATION CHECKLIST
u1!System lnslailation ❑Tank(s)Only .❑Drainlield•Only ❑Repair ❑Other
System Type. 4'!!i o;V Pretreatment Type -
>5:ft.from foundation? -...---- ------------------- O NIA O N
>50 ft-from wells? .------------------------------------------ ❑'
Z >50 ft.from,surface.water? -------------------------------. ❑,
Cleanoutbetween building and tank? --------------------. ❑ "
t) Tankbatifespresent? .----------------------------------- ❑ .❑
24°access risers over each compartment?'--------------------.- -,_ ___., ` ❑:
Effluent fiterinstalled? _---•--------------------------- O Cl
Septic tank capacity(working)' ,/3"+d' gal Manufacturer / f(a
fl D-box water lever and speed'levelers,used? ------------------ ❑i WA. 3. 9 ❑NO
3 t6 Manifold/D-box accessible from surface?---- --•- -_--.--- - ❑ Qr"" ❑
mz Check valves installed?
OCC 1d
Transport Line Size 41 Schedule/Class
Bedrooms installed(check one) 2 ❑3 ❑4 D's :06 ❑Commerclaloiher
>10ft.fromfoundation?----------------- ----- -- ❑,NWA es O No
II >100 ft.from wells?---- -------------------------
7100 ft from surface water? -- - --- -- --•------ ❑ l-' ❑
tL >10 ft.from potable waterlines?-------------------------- ❑, [a/' ❑
i Z >5 ft.from;property limes and easements?----------------- O i'�.
1 >30 ft,from.downgradient curtatn/toundalion drains?--- ----- r❑+�
® Drairl level and observation ports present---------------- ❑; lfd' ❑
i34raveless chambers or '❑ Clean,graver used? (check one) ,�f
M
Proper cover installed over drainfield?- ------------------- ❑
Pump tank setbacks,consistent with septic tank?--- ❑ NrA ❑YES too
Pump t flood) cal Manufacturer
Q 24"access user(s)and ace surface?.---------- '❑ ;❑ O
Alarm or Control Panel ----- �untar
- ---__-_ _ '❑ ❑ ❑
Control,Panel equipped with Tmer/ --- --- ❑ ❑
Pump installed.In Bpr,I or, ❑'an Block or ❑ Other
Pump f�:n O'Plosa or 0 Trencduce
m T raw dawn' infmin, Pump capacity cpm SqulrtHei9 ght ft.
: $_ ,'PUr1�p-on#lmt P.ctmp off tune Datty flow'set at p d
Mason County OSS Installation Reportlpg._2, Parcel#__ / ill 9bD'2res
ABANDONMENT RECORD
Were existing septic components.abandoned as part of this project?' - -' ------- -..-- Q y�
If yes,please describe:
Were ai{components pumped out:andproperty abandoned:per WAC246-272A-0300? --- ---- []YES WA& NO
RECORD DRAWING
This is a varman.nt yacard and m®L.be aeerunra and desvlpitvo enough se rs-lacWA In ths need of raahseanee actMU.a-rnd fSrbue.devefopaunt. T pi Red
Draw mWrr,orar<mea&MMWd adentaticn a layout,Stptkdpmap lank location.No*a w.resarvedrala d,o6a ing and isoRosod lad1d ja.IocWan etwail.;wataAnas,
viola,absWafian pods,c1m=ts,and o�ermaUtte=f;g.aaesa points.lncamplela Ramid Dtawings may seats eamBenel Cwys lnmmt:FhsiaOauanappmval and fwd permp:
0Lv Z- ! S
S, &r' Sptrc +ciriL
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ecord DsaMng,Afached '
CERTIFICATION OF INSTALLATION:
INSTALLER DESIGNER!ENGINEER
i certify that 1 installed the system in accordance with I certify that the system has:been installed in actor-
the septic design stamped'APPROVED by Mason . dance with the septic design stamped"APPROVED by
County Pub tic Health and that any deviations shown. Mason County Public Healfh..and,thatany deviations
here have boon cleared/approved by both the designer shown here have been clearea/ePprovad by both
and Mason County Public Health and meet all State myself and Mason County Public Health and meet all
and Meson County Codes, State and Mason County Codes
I further:certify that all infonnafl ntained on this I further certify that all information contained on.this•
form and attach D gis accurate.. i form,and attached Record Drawing is accurate.
Signature of Installer D e 3' '
Printed Name ofSignee• 4; ' $
MASON COUNTY PUBLIC HEALTH •' 4.• e",r3
The undersigned approves this.Installation Report and , .��-��-� 3
Record Drawing.an behalf of Mason County Public.
l-fee!th: .. ) $1AL
Signature of E►vaunmerliel f tealrh Specialist Date
(mrnp.signature ant!tiate)
THE MASON COUNTY WEB SITE
L l i r 1 '�°�°" ! ,$EiSCEWN�]ANDAVAtW�@!:E FaR USLI VIEW ON �aa�nam
d1�i 6 RECORD DRAWING �o�0000Qv �
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360 c P.o.- - r Cieaerve)
// I To?- - F ztw'i•" __ Y -- "d FI
i i F�. 4 a1 ,� APPROVED
/ ti 1a 0EC 1 0 2025 Ada �11d; ' i Fq
t I J 1. DRAINFIELD ii d h
/ i / �NyOti CJ4Ti EfIY{?,Q4MFtiIALNrAV
' P,ET
\ 3. pj5-a CAL. CnNCRry'_E SEPTIC 7ANt. _._ H Cri.2�li
J.• 10e 4. :T"rdc.r.✓.:� .6vX1 i
!i3sm �C3y Yir..•vru.d,E.in
- a
rzc,- .'"" L''t i%Tvo gr n S7az iW -( :✓4'/ cr�rti�Cot� ........_...-.......- i
may= .
,dcdE'.ES i 3*•r6p' aya;�• "-- WATERLINE;MUST'BE LOcaTED MIN.10 -
OVERALL SITE PLAN.1"=100' FROM ALL SEPTIC SYSTEM COMPONI NTS J {
ADVANCED ENGINEERING OWNER: LEGAL DESCRIPTION
128 N.River Street
>' ' .''r ayse 1S/1 T:19 R swT.P.xc s'9ry^yi y - I JOB NUMBER_
Monte9nno,WA 98563 6 SD' /ao
DATE,
360-249-8447 u��v it w.4 98t'sz - LoTz: sp h3o�/a SCALE / g '
� _I
24' 3g•. _ 24'_._-�6' �� E 1�
��--_ 2,500LB WHEEL LOAD W �• /• t
(CENTER OF LID)
,_
LE
152 = 1'4
TUREDXX/XX/XXXX F.G:-'
COVER: 3 FT.
TY: 1165 GAS, .�.
12' MIN, COVER
36 MAX. COVER '' ��,.'•()tit��'`
-DETAIL I.O.TAG
(RCA TAD INSIDE RISER
OR
1 VASoo ' ip�
ACCC ESS OFEN!NG,TIP.)
ACCESS AND RISER NOTES 4, �LC
I. MINIMUM➢ 16. 0lA ACCESS OPENING PER
I
ens
COMPARTMENT.THE DISTANCE BETWEEN ACCESS g' tgjN, it o
OPENI!ES IS NOT TO EXCEED 10'-0- CENTER TO CENTER. ' y t a
R. RISERS RUST LE A FIIN/P.L�t1 OF 23'INSIDE
_ 16' MIN
DIAMETER. �-.-' m m
3. RISER-TC-TAN.< AND RISER-TO-ADDI7IO!JAL 4' DIA. 20' t-0AX. CAPACITIES (GAL.)SECTIONS OF RISER CONNECTIONS MUST
INCORPORATE GROOVES OR ADAPTERS TO PASS-THRU� O E oN
INCORPORATE
JOINT F-.OVEY.ENT AND REMAIN çi
WATOPERATING 3? mW rCOVERt°
4. ACCESS AND RISER OPENINGS MIST BE 5,000 PSI C❑NCRETE
T❑TAL CFLO❑D)15� a min,
SECURED
WITH A LOCKAELE LID OR OTHER
SECURED LID. 4(ALLS, FLOOR, AND
E ACCESS RISERS AND LIDS MUST BE
STRUCTURALLY SOUND TO WITHSTAND „i /'LID. TYP. I
ANTICIPATED SITE-SFECIFIC LOADS. f�= L3
CAPACITIES (GAL.) y 3 ' ! _
-J _
SEALS AND GASKET PiDTES _ H OPERATING 787 1 wP
-I II
T❑TAL (FLOOD) 942
1. SEALS AND GASKETS FOR INLET.UTLBE AND - `�
INTERCOIL VA E R-TI TIT, 'GS MUST BE RESILIENT, VATER-TIGHT, L�
CEALS EETINGISTANT,AND FLEXIBLE.
2. SEALS MEETING AST11 C-1644 OR EQUIVALENT _
RUST HE USED AT THE TANK WALL-TO-PVC 2I'• TAPER \_S.ONE-FREE NATIVE IVE SOIL OR
Q
MUSTPIPING INTERFACE TO PREVENT LEAKAGE. -' �- i2 P 4" T T
TYP. 4 SIDES COMPACTED SAND OVER STONY SOIL
INSTALLATION INSTRUCTIONS I {- BAFFLE NOTES WATER TABLE AND
TRAFFIC LOADING NOTES
I. EXCAVATE TANK MULE WITH VERTICAL WALLS TO 2 FEET LARGER THAN TANK ON ALL SIDES. I. INLETS TO SEPTIC TALCS MUST EXTEND AT LEAST 8' ELOW THE FOR TANS MODEL 1156S:
TOTTON Dl HOLE RUST BE FLAT, LEVEL, AND FREE E6•WATER HOLE MUST SLOPE DOWN 3' LIQUID LEVEL A MAXIMUMI WATER TABLE NOT TO EXCEED TOP _
TO CENTER OF TANK. 2. OUTLETS TO SEPTIC TANKS MUST EXTEND BELOW THE LIQUID or LID
2. INSTALL 6' MINIMUM OF 2' MINUS MATERIAL OR SAND ON BUTTON OF EXCAVATED HOLE. LEVEL AT LEAST 30%BUT NOT lORE THAN 4DG. E RA%IMUl1 TRAFFIC LQABING NOT TO EXCEED 2125/21
3. INSTALL TANK'N CENTER OF FmLE,KEEPING IASRE11 FOOT VOID SPACE OM ALL SIDES. 3. INLET AND OUTLET DEVICES MUST HAVE A MINIMUM INSIDE 2303 LB.CONCENTRATED LOAD.4. INSTALL REST OF SYSTEM.AND AFFIX RISERS AS REQUIRED DY LOCAL JURISDICTIOl1 DIAMETER OF 4' AND E£ CONSTRUCTED OF PVC OR ABS S.T.B.
S. UPON APPROVAL TO BACKFILL,FILL VOID SPACE AROUND TANK WITH COMPACT GRANULAR CONFORMING TO OR EXCEEDING THE STANDARDS OF AST11 D 3034 FOR TANK MODEL 115OS-HW:
(SANDY)SOIL FREE OF LARGE CLUMPS OF CLAY AND ROCKS OVER 2' IN DIN PACK OR AST 2600,D 2690,RESPECTIVELY. A MAXIMUM WATER TABLE AT GROUl1D LEVEL. R.C.Z.
FILL CAREFULLY AND EVERY IN IB• LIFTS. MAXIMUM SDIL COVER 1S 36' 4. INLETS AND OUTLETS PLAY BE MOVED FROM THE LOCATIONS
6. IF REQUIRED,WATER TEST7IJG TO BE DONE BY LOCAL JURISDICTION OR DOH SPECIFICATIONS. SHOWN PROVIDED INC HEIGHTS ARE NOT CHANGED AND THE PIPE D 2350 MUM TRAFFIC
LOADING
UA DhLOAA TO EXCEED N.T.S.
7. FINAL GRADE THE SURFACE TO AVOID CHANNELING SURFACE WATER TOWARDS TANK. CENTERS ARE LOCATED AT LEAST O' FROM ANY EDGE AND AT 24x3DD
LEAS' 4• FROM ANY REHAR.
1OF2
VERT.RERAN f?J
6' 24' ( 3B•_--..�-----24' b• ,�, (SEE SCHEDULE) fl I
^ f B1/2 COVER _2•HBR CCVER
_ 7F'•� VERT BARS IZ BARS
�mvm��v_�®�
1 1 ! II
f _
(SEE SCHEDULE)
pc=
0 24• —- _ ° + _ L = Q 1_Li) REINFI RCEtdENT R i c
I Q o =Q = I R12REBAR° J."NE SCHEDULE)
— 24' DIA OPENING — ---=1==•___�� = E!V�_. - 2 PLACES)
4=== — __ _=—p= -=_O=__° 5,DOC PSI 3'TIIICK— TANK SIDE WAIL ngTAIL.
p
CONCRETE VALL ==3
5,000 PSI CONCRETE (SEE SCHEDULE)
'LID(SEE TABLE) ,1,c
FIBER SCHEDULE FUR 1150S FIBER SCHEDULE FOR 115DS-HW o S.
TANK AID III TAIL (3'OF SDIL CDY<E,WATER TAME Al LID,MD LR WHEEL(((ADS (3'Di SL COVER,VAIER TAME AT LID.250D Ll.VBCEL LOU) Ny J
a
SIDE VALLS,END WALLS. LID(THICKNESS 4') SIDE VALLS,END VALLS, LID(TH:CKNESS 4') X W O
IN RI
1NTERCOMPARTP.EOTAL ---- INTERCO}7PARTHENTAL
WALLS,AND FLOOR DIAMETER 114(1/2') i VALLS,AND FLOOR DIAMETER R4 (I/2') "r-1 to N
FIBERFOR+:F.
•
FIBER TYFE 750- SPJICIN3T 16•E.M. F]IIER TYFc FIEERFORCE 750 SPACIt:G 12' E.V.
D03AGE NOTE: NOTE:
DDG(PER-E 5 LB. TAUT LID HAY USE FIFER DOSAGE TANK LID MAY USE FIBER
VENT.REBAR OF CONE) REITJFURCEIENT AS PER AT (PER CV 5 LB.
I LE 'F HOWEVER.E AS L PER AT
(SEE SCHEDU'_C) { LEFT.USE REEK,LID MUST OF CUTE.) LEFT. LID CHART.
ALSO REBAR PER CHART. ALSO USE REEAR PER CH
a ... t - qr =- I
v -- -- - .-, - FIBER REINFORCEMENT SHALL MEET (FE REDUIREIf£HTS OF ASTH C1II5,SECTION q.13 AND NOTE 2 AND ASTH 07500.
Q ° II II - ° FIBERFORCES50 KAY EE SUBSTITUTED FIR FIEERFORCE753 AT THE SAFE DHSAGC RATE.
REBAR SCHEDULE FOR 1159S REPAR SCHEDULE FOR 1150-HW
u I ° (3'EF SOS.COVER.VAIER TABLE AT LID.2STD LR VDEEL LOU) (3'IV DEL C(NER,WATER TABLE AT LID,2590 LB.VIIEEL LUAU)
1°I II II Q I Q Q SIDE 4/ALLS END WALLS SIDE WALLS END WALLS
II Q _ __J___JL_0----IL I HIRIZ.DIA. ((3(3/B') HDRIZ.DIA. 03(3/E') °19812.RA 03(3/8') HBQ12.CIA. 03(3/B')
Q I HORIZ. REBAR I p ° HERTZ.SPACI!JG _ IB' HEIR1Z.SPACING IB• HIM.SPACINTi 16• H0.QR,SPACING IB•
QI p II I(SEE SCIIELJLE) I Q I VERT.DIAL113 I3/B9 VERT.DIA. 43 t3/B•) VERT.CIA. 83(3/8•) VERT.DIA, R3(3/8•)
VERT.SPACING IB• VERY.SPACING IB• VERY.SPACING IA' VENT.SPACING
I .
II Q p 1 Q 1 FLOOR LID (THICKNESS 4') FLOOR LID (THICKNESS 4')
1 Q Q i DIAHETER 03(3/6') DIAHETER 94 (1/2•) DIAHETER (13(3/6') DIAMETER 94 E]/2') 1. 2)25121
_ __ SPACING 107EV. SPACING IB•E.V. SPACING 10•E.V. SPAC(1Ju !2' E.V. S.T.B.
NOTES.
S,ODD PSI 3 THICK TANK SIDE 41A!Ljl�TA]I_ 1, ALL REINFORCEMENT IS TO BE ASTH A615 GRADE AD WITH A MIN.OVERLAP OF 30 EAR DINGELERS AT SPLICES(EBL 15' •� R,C,Z,
CONCRETE WALL FOR 94 EAR)
(SEE SCIEDULED 2. UNLESS NOTED OTHERWISE,FLOOR MID WALL SEDAN IS TO EE CENTERED IN THE CONCRETE MEMBER WITH THE HORIZONTAL N.T.S.SEDAN TOWARDS THE OUTSIDE OF THE TANK. N.T.S.
3. REINFORCEMENT FIBER (NOTED III THE UPPER CHART) IS INTENDED AS AN ALTERNATIVE TO THE REEAR(NOTED IN THE
LOVER CHART).THE LID REQUIRES REBAR REGARDLESS OF THE WALL REINFORCEMENT.VHEU FIBER REIHFORCEHEIIT IS USED
FOR WALLS,A SINGLE 93 IBBTP IS TO BE PLACED Al'THE TOP OF THE TANK WALL FOR ^I HANDLING STRESSES. ''+s1
2OF2