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Home My WebLink AboutWAI2026-00062 - WAI Health Waiver - 8/3/2026 4'5 N.6"'STREET,SnELTCN WA 96584 MASON COUNTY aELrI °q By Public Health & Human Services JUi 7 [02 �� Application for Waiver or Appeal Amount Paid �I� Receipt Number aG tp 033i � WAI D -(p _ Gcoe) Please note,all approved Onsite Waivers have the same expiration date as their OSS Permits. Instructionsi. : Complete Pars 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 David & Kathryn Ellingsen Telephone 208-410-7237 Mailing Address 3519 E 3980 N City Kimberly, State ID Zip 83341 Parcel No. 3 1 9 `} 2 4 0 0 0 2 0 Site Address 900 SE Dahman Rd, Shelton, WA 98584 Subdivision Name and Lot PART 2: Nature of Waiver/Appeal S c, 7ozs-sv9 9 -g Onsite: Class A Waiver O Food Sanitation Requirements ❑ Onsite: Class B Waiver O Group B Water System Regulations ❑ Onsite. Class C Waiver ❑ Water Adequacy Requirements ❑ Building Permit EH Review Policies ❑ Onsite. Holding Tank WAC246-272A- O Appeal Enforcement Timelines 0240 ❑ Appeal Departmental Determinations ❑ Onsite: Contractor Certification O Other Requirements Description of Waiver/Appeal !include justification, additional material may be attached.!'. Reduce setback from drainfield to top of bank from 50' down to a minimum of 30 . Mltloatlon is that septic meets Treatment Level B without disinfection with pressure distribution and timed dosing Vertical separation is over 24 , Geotech has approved 30' setback for development. Vegetated slope well remain retaining slope stabib ctl d I I l� \ (.a. , � Date: F Applicant Signature: 'cQr ar ,, 003.09.2026 --rJ This form may be scanned and available for public iew on the Mason County Web site. Page of PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) E]Appeal ❑Waiver 17 Class A ❑Class B ❑Class C ❑ Local State Waiver Criteria Number of Bedrooms:6 Nitrogen Treatment: 17 Yes ❑ No Soil Type. 4 Minimum Lot Size: 43560 sq.ft. Water Source:❑Public DPrivate This Lot Size: 242,193 sq.ft. Is This Lot Eligible for State Waivers: Z]Yes ❑ No ❑ N/A Hearing Official. l] Environmental Health Manager ❑ Public Health Director ❑ Other 2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest Code/ Standard revision): zn6-2rznozmp7 Tame IV 3. Nature of Appeal. Reduce the minimum horizontal separation between the soil dispersal component and down-gradient cuts or banks with less than 5 feet of original soil above a restrictive layer 50 feet to 30 feet 5. Mitigating Factors: 1) System is Treatment Level B, with pressure distribution and at least 2 feet of vertical separation. 2) Established O&M program. 3) Evidence of slope stability. Geotech report dated: f/Z /in z c 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy ha en submitted. Staff Signature: . ,_ Date: 1QZ6 PART 4: Determination of the Hearing Official LrJ 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: $4 am/ S94cn.41sc ON /'/� /tna/c/- Mj ill l rK-9Lr ❑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: 2Wt "'^'W,7t</ Date: Revised 03,032026 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 On-Site Sewage Systems (Chapter 246-272A WAC) ' H EALT H Request for Waiver from State Regulations is Section 1. (Completed by applicant) Local Health Jurisdiction Received(2) Name: (1) David & Kathryn Ellingsen (See instructions) Address 3519 E 3980 N ROM C141y Kimberly, ID 83341 / Telephone 8) 410-7237 ...... Signature: 7_'r3F ZS° Property Identification: (3) PCL 2 OF BLA#23 19 AF#2201931 PTNS OF G.L. I &2 PENDING BLA 26-04 AF#2237991 S57160 S 29/145541/48-49 S 53/184-185 Parcel#31914-24-00020, 3E014,TWP19N, R3W Section II. I (Completed by applicant) WAC Number:(4) WAC Requirement: (5) Waiver Sought: (6) 246-272A- 0210 (1) Drainfield to be 50'from top of Drainfield setback reduced from 50 Subsection: steep bank down to 30 minimum justification (Proposed mitigation measures): (7) -. Septic meets Treatment Level B without disinfection with pressure distribution and timed dosing. Vertical separation is over 24". Geotech has approved 30' setback for development.Vegetated slope will remain. Section III. I (Completed by local health officer) Review Criteria: (8) Additional Mitigation Measures: (9) Comments/Conditions: 110) see- c 5I A .raiW_ p4(KP/F_ Type of Waiver: (11) Class A flClass B flClanass C— Request DOH review before granting? Yes❑No Neighbor Notification: (12) Required?Yes❑No I t/ If needed, are agreements, easements, etc.filed? Yes ❑ No❑ Section IV. /Completed by health officer) This Recuest for Waiver from State Regulations has been reviewed according to the provisions of Chapter 246-212A 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 hearth protection at least equal to that provided by this chapter WAC. Denied ®Approv / ranted —Subject too all comments, conditions anc requiremen note in Sections II and III. Date: V Local Health Officer(13)i�""" DOH 337-175 February 2024 Instructions for Completion Sections I and II are to be completed by the Applicant and must be submitted to the local health jurisdiction. Sections III and IV are to be completed by the local health officer or their authorized representative. Most items in each section above are followed by a number in ( ). Here are the instructions for each: (1) Individual requesting waiver(presumed to be property owner; indicate if not): include the mailing address and phone number. (2) Local Health Jurisdiction:Jurisdiction with the authority to approve OSS permits in the system's county.County staff typically complete this field using a county stamp. (3) Property Identification: Provide the address, parcel number, permit application number or other identifying description of the property for which a waiver is being requested.A full legal description is not required. (4) WAC Number:Specify the particular WAC number from Chapter 246-272A WAC for which a waiver is being sought, such as "WAC 246-272A-0210(1)." (5) WAC Requirement:State the requirement in the specified WAC for which a waiver is being sought, such as"100-foot setback from soil dispersal component to a well (6) Waiver Sought:Briefly describe the waiver sought,such as "reduction of setback to 70 feet" (7) Justification: Provide the rationale for the waiver request.What site conditions,system design characteristics, etc. mitigate the deviation to satisfy the WAC's intent? Justification should include supporting technical data, plat plans, device or treatment methodology proposed, possible mitigating site characteristics,gross land area, other options explored, and any other pertinent data. Possible mitigation measures may include system design,site requirements,or administrative approaches. Attach additional pages, if necessary,to provide the local health officer with adequate information upon which to make an informed decision. (8) Review Criteria: Indicate specific criteria used in the review of the proposed waiver and mitigation measures. (9) Additional Mitigation Measures: Indicate any mitigation measures required in addition to those proposed by the applicant. (10) Comments/Conditions: Briefly describe concerns regarding the waiver request, mitigation measures, or related issues. (11) Type of Waiver: Indicate which category of waivers this particular request falls under. For Class C, indicate if DOH review is requested before a decision is made to grant the request. (12) Neighbor Notification:Are there any aspects of this waiver request for which notification to and/or permission by, adjoining or nearby property owners/dwellers would be appropriate? (13) Local Health Officer/Authorized Representative:The local health officer must check the appropriate box and ign,grant or deny the waiver request. F alth De artmen /Distrir. Heath Off cers nay obtain assistanceAssistance for applicants recreating a"Waiver from p review ofState Regulations may be dbtaioed from.[hz Local Washington Slate Depa tment of Mealt^ . e M1Heal Department or District. d "Waive from State Regwabors'by contactingaterMgmt@doH wagov. To request this document:n another format,call 1-900-525-0127. Deaf or Hard of nearing customers,please call 711(Washington Relay)or email doh.informati0nd0h.WPv. 2 DOH 337-175 Febr_ary 2024