HomeMy WebLinkAboutWAI2026-00068 - WAI Health Waiver - 8/5/2026 415 N.6'"STREET,SHELTON WA 98584
MASON COUNTY SHELTON:BELFAIR:360-275-4467,ext.400
Public Health & Human Services
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Application for Waiver or Appeal
Amo nt Paid I 0 Receipt Number: a(b2ta - 6351
WAI )fl1Go- C7CDLY
Please note,all approved Onsite Waivers have the same expiration date as their OSS Permits.
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 RAICHLE LIVING TRUST Telephone 314 882-3395
Mailing Address PO BOX 3271
City BELFAIR State WA Zip 98528
Parcel No. 2 22 1 2 _ 5 8 _ 0 0 0 1 7
Site Address 17511 E STATE ROUTE 106, BELFAIR 98528
Subdivision Name and Lot LAKEWOOD PLAT L TRACT 5A S 54/68 S 54/69
PART 2: Nature of WaiverlAppeal
❑ 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.):
Sewage tanks 50' from surface water down to 25'
Sc& : I13L
Applicant Signature: 1i/& p/ 4- Date: / 5
I Revised 03/03/2026
This form may be scanned and available for public view on the Mason County Web site.
Page I oft
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Appeal OWaiver ❑Class A ❑Class B ❑Class C ❑ Local
State Waiver Criteria
Number of Bedrooms:_ Nitrogen Treatment: ❑Yes ❑ No
Soil Type: Minimum Lot Size: sq.ft.
Water Source:❑Public ❑Private This Lot Size: sq.ft.
Is This Lot Eligible for State Waivers: ❑Yes O No ❑ N/A
Hearing Official:
❑ Environmental Health Manager ❑ Public Health Director ❑ Other:
2. Identification of Specific Code/ Standard/ Determination (include date of determination or latest
Code/ Standard revision):
3. Nature of Appeal:
5. Mitigating Factors:
6. I have received this waiver/appeal request. It is complete and mitigation required by the state
and local policy has been submitted.
Staff Signature: Date:
PART 4: Determination of the Hearing Official
O 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:
Revised 03/032026
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
EXHIBIT "A"
HORIZONTAL STRUCTURAL REINFORCING RIBS GAS(TOP)/LIQUID(BOTTOM) TOP
(FULL CIRCUMFERENCE) ---- PASS-THRU SLOT INSIDE TANK
LIFTING-4Z
HOLES IMTh I
I Ii
(4 TVPICAL) (
THREADED
ACCESS �� psP 1
—tia o
24 I.D.DIA. )
(2TYPICAL) i �1S(: 'II I L
4.25TYP.
- 29112"TYP.
LENGTH=118"118"
_ WIDTH=62' -
8.66',
X02 Treatment & Discharge Tanks ____ __
TANK SPECIFICATIONS 2,'' III Ill
DESIGN CAPACITY TOTAL CAPACITY WEIGHT III '' j �
GALLONS LITERS GALLONS LITERS POUNDS I, L
1000 3]80 114, 4340 450 J _ - SIDE
ROTH MultiTank® RO
1000 GALLON / MODEL RMT-1 OOOE
('lass C Wa ver Mil gal on M asures
1)Extra protection of integrity of poly tank.
to)Waterproof tank penetrations with bentonhe. Flexible rubber
boots or compression seals or flexible couplings used for inlet
and outlet connections to provide flexibility in case of tank
settlement while still maintaining a watertight seal.
2) Performance testing of tank
2a)Poly tank tested for water-lightness-
3)Accessibility of tank for ease of operation and maintenance
3a)Access openings at or above finished grade with lockable lids
or secured to prevent unauthorized entry.
o RAI H IVIN TR IST Site Info: Parcel#22212-58-00017
a Mailing PO BOX 3271 17511 E STATE ROUTE 106
BELFAIR WA 98528 BELFAIR, WA
On-Site Sewage Systems (Chapter 246-272A WAC) ' • HEALTH
Request for Waiver from State Regulations
Section I. I (Completed by applicant)
Name: (1) RAICHLE LIVING TRUST local Health Jurisdiction Received (2)
(See instructions)
Address: PO BOX 3271
BELFAIR, WA 98528
Telephone: (314) 882-3395
Signatu jj j
Property Identification: (3)
LAKEWOOD PLAT L TRACT 5A S 54/68 S 54/69
Section II. (Completed by applicant)
WAC Number:(4) WAC Requirement: (5) Waiver Sought: (6)
246-272A- 0210(1) Sewage tanks 50' from surface Sewage Tanks down to 25'
Subsection: Table IV - -- Water _-_-- -- ___-- _--- _--
Justification(Proposed mitigation measures):(7)
1).Seal tanks penetrations with Bentonite
2) Tanks tested for water-tightness
Section III. (Completed by local health officer)
Review Criteria: (8) Additional Mitigation Measures:(9)
Comments/Conditions: (10)
Type of Waiver:(11) Class A Class 6 Class C—Request DOH review before granting? Yes flNofl
Neighbor Notification: (12) Required?Yes❑No❑ If needed,are agreements,easements,etc.filed? Yes ❑ Nofl
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 ❑Approved/Granted—Subject to all comments,conditions and requirements noted in Sections II and ill.
Local Health Officer(13) Date:
DOH 337-175 February 2024 I