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Home My WebLink AboutWAI2026-00051-APPLICATION FOR WAIVER/APPEAL - WAI Health Waiver - 8/10/2026 oacusion Envelope ID:79232rc6-0350-882E-8036Aeo4E7B98t LD 415 N.6"STREET,SHELTON WA 98584 MASON COUNTY SHELTON:360- 7 670,ext 400 COMMUNITY SERVICES BELFAIR:360- ELMA.360- 4F. 4] BUII41ngPUnrvng Envlrcnmendl Health.Community Health Application for Waiver or Appeal JUN 7 ? 2i)1 "' Amount Paid: IC Receipt Number: � n ' , „ WAI a�a - 0OO51 Instructions: 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 Information Name of Applicant KO Home Services Inc. Telephone 360-620-9960 Mailing Address 12271 Orchard Ave SE City Olalla State WA Zip 98359 Parcel No. 2 2 2 2 3 -- 7 7 -- 9 0 0 2 2 Site Address xxxx E Rasor Rd West. Belfair WA 98528 Subdivision Name and Lot No. 2623 - NE 1/4, NE 1/4,Section 23.TWP. 22N., R. 2 West,W.M. Lot 2 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 0 Water Adequacy Requirements ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards ❑ Departmental Determinations ❑ Contractor Certification Requirements 0 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 Signed w. �� Applicant Signature: ,�. 1}MAt.E' Date: 6/9/2026 E1501CFSOF476.. Revised R 2121117 This form may be scanned and available for public view on the Mason County Web site. Pagr I of 2 Docusgn Envelope ID'.79232FC6-0350-882F-8036-BBD4L7B9b16D PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) Appeal yWaiver - 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 PRESSU RE OSS. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Hoard El Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN 7v/�"3�) 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local polio a been submitted. Staff Signature: Date: PART 4: Determinate of a Baring Official IR 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: t/7�esc ..ar Date: Revised R 21;?017 This form may be scanned and available for public view on the Mason County Web site. 'age?oft Docusign Envelope ID:]9232FC6-0350-882F-8036-BBD4E799B1 ED SERVICES MASON COUNTY MASON COUNTY PUBLIC HEALTH COMMUNITY rMN CLASS B WAIVER WORKSHEET 415 (State and Local waiver forms required) SHELTON360-427-0670REC 400 BLDG BELFAIR.360-275-446],EXT.dW ELMA.360111115a EXL 400 -FAX:$60-4L-)]e6 AVYLIUNF NAME KG Home Services Inc- WAPJER PEnMrr NUMBER WAI MAILINOADORESS 12271 Orchard Ave SE CITY Olalla STMT WA ZiP 96359 sirE ADDEESS xxn E Rasor Rd West cnry Repair TAX PAFCtL NUMBrE 22223-Trd002z PROPOsED DRAINnsm TYPE ® CONVEYTIONAL GRAVITY ❑ CONVENTIONAL PRESSURE 1.SOIL SERIES: S.VERTICAL SEPARATION: The soil Series must be Alderwood Har5nne,Hoodsport Up-slope vertical separation must be greater than 18" Shelton,of Slndalr Gravelly Sandy Loam, far gravity and greater than B'for pressure. Alderwood Gravelly Sandy Loam ® Greater than 12 ..................................................... ......-❑ Harsme Gravelly Sandy Loam .. _. ❑ Greater than 18 .......................................... .............. El DI Hoodsport Gravelly S ndy Loam._. . ... ❑ ❑ -Determined by: (` Shelton Gravelly Sandy Loam ... ....❑ ❑ Depth to hardpan Sinclair Gravelly Sandy Loam ._. _--U ❑ Depth to mottling ..... ..... ❑ Other—.._. . _ .....❑ ❑ Both.............. ...... ._.. ❑ 2.SOIL TYPE: 6.WATER TABLE LEVEL: Soil types must be Medium Sand,Loamy Sand.or Sandy If test holes show evidence ofd seasonal water table Loam-Gravel percent must be less than or equal to 359-4 above restrictive layer,a curtain drain maybe required Medium Sand. _. ❑ ❑ = Evidence of seasonal water tabl Loamy Sand_- .... _.❑ Yes ........ _.. ............ ❑ ❑ _sandyLoam Percent Gravels o Curtain Drain required: Less than or q o It 3s ...... _- ® rYeyl Yes _- .-- ......... ❑ Greater than 35%..............................................0 g No .... .... .. ® 3 3.SOIL DRAINAGE: c 7.HORIZONTAL SETBACKS: � Soils must be moderately well drained to well drained. o Primary Oral held must maintain]W'from down-grad- o = ent marine shorelines surface waters and wells. Well Drained.. .......... .......... ❑ Moderately Well Drained ......._...® -Are increased horizontal setbacks met: Other .............. ❑ Yes ............ ......._ ..............-... No ❑ 4. DRAINFIELD SLOPE: 8.ATTENUATION ZONE Slopes must be between 3%to 301. Gravity is only allowed on slopes from 3%to 15%. A 50 foot horizontal attenuation Zone is required 1 Pressure is allowed on 3%to 30%, down-gradient of the primary drainfield. Less than 3%..........................................._..................... ❑ Q. -Is there 50ft or greater between the down 3%to 15%....... ............ . ................. ® gradient side of primary drainfield and.. 16%to 30%............................................................ 0 property boundary: Greater than 3O%................................................... 0 Yes . ....... ....... .._._. The 50 feet horizontal attenuation zone is requiredzone is be recorded on the deedtion o property asunbuil N. 2244 �3 prior to design approval The attenuation zones met to be used for the r musty agree of these decks,pati z AFN' L Ly parking areas,vehicular Ivni or ether similar such uses.The owner must agree to all these conditions. Pr�ierl.co,di "I THIS FORM MAY BE SCANNED AND AVALA a10x Puete STEW nn THE MASON courvttweesn3 +Pea Decoction Envelope ID'.79232FC6-0350-802E-8036-HBD4E75981 ED Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC Effective Dare: July 1, 2007 Revised April 2017 On-Site Sewage Systems (Chapter 246-272A WAC) Request for Waiver from State Regulations Section 1. (eonrplated on applicant) Name: (1) KC Home Services Inc Local Health Department'District (2) (see 1Retrnchanl) Address 12271 Orchard Ave SE Olalla,WA98359 Telephone ( 360 )620.9960 Signature: Property Idth1kWP.W6 Parcel No 22223-77-90022 xxxx E Rasor Rd West _--- __- _--- ---- - Blelar.Wa 98528 Section H. (completed k' applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A- 0230 24" OF V/S FOR PRES E (OR) 12" OF V/S FOR PRE URE OSS (OR) Subsection: TABLE VI 36" OF V/S FO AVITY 18" OF V/S FO RA /I OSS Justification (mitigation measures lobe pr-orlded): (7) C ED CLASS B WAIVER CHECKLIST ACHED, (OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN. ZONE (AFN: Section Ill. (completed br health officer) Review Criteria. (8) Mitigation Measures(in addition to those proposed): (9) -` Lt 33-- Corn mcii ts/Conditions: (10) Type of Waiver (11) ( ]Class A pd Class B [ ] Class C—Request DOH review before granting? Yes No Neighbor Notification: (12) Required? Yes No /fneeded, are agreements, easements, etc properlvfled? Yes No Section IV. I (completed by health offeet) 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. i ] Denied iJQApprove Granted—Subject to/all comments,conditions and requirements noted in Sections 11 and III Local Health Officer (13) �/ ' — Date: DOH 337-021 Page 26 of 32