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Home My WebLink AboutWAI2022-00076 - WAI General - 6/3/2022 rirA 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 4p_plication for Waiver or Appeal 2:1 VD Amount Paid: Receipt Number: •illa • WAI 101 ! ' 14 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 JORDAN TURNER Telephone Mailing Address 230 E NELSON ROAD City ALLYN State WA Zip 98524 Parcel No. 1 2 2 2 9 =- 4 3 -- 0 0 0 2 0 Site Address 230 E NELSON ROAD- ALLYN Subdivision Name and Lot PART 2: Nature of Waiver/Appeal IY Class B Reduce Vertical Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies 0 Group B Water System Regulations O Location, WAC 246-272A-0210 0 Water Adequacy Requirements 0 Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations O 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 r'nCCcun: OSS CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE Applicant Signature: .VA.. .----, r Wiefivik- Date: (p l4 Zw i 4 1V/ - • P Revige l p/21 7 This form may be scanned and available for public view on the Mason County Web site.ii.� 1� 2Q22 I J Page 1 of 2 Lh, PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver (if applicable) ❑ Appeal VWaiver Li None required ❑ Class A yr"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 CONVENTION GRAVITY 0 PRESSURE OSS. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director 0 Certified Contractor Review Board 6r Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN ') t $44 35 ) 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: '"[`1`?•0'3^r)e- PART 4: Determination of the Hearing Official ri 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: 0 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: Y7 Date: ��2-- Revised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 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) Local Health Department/District (2) JORDAN TURNER (see instructions) Address: 230 E NELSON ROAD-ALLYN HG-dee.% P.tP , r4iiirl • 41,5 ' - a- Telephone: ( ) Signature: giL /\ _ ‘ i Property Identification: (3) 1 2 2 2 9 - 4 3 - 0 0 0 2 0 230 E NELSON ROAD -ALLYN Section II. (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A— 0230 Subsection: TABLE VI 36" OF V/S FOR GRAVITY 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: 1.1 g 4 L3 S ) Section III. (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (10) Type of Waiver: (11) [ ]Class A yt Class 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. (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 piApproved/Granted—Subject to all comments,conditions and requirements oted in Sections II and III. Local Health Officer (13) Date: / r4 DOH 337-021 6 �' 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 WA 98584 (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 JORDAN TURNER WAIVER PERMIT NUMBER WAI .}a 1.-7- - p oit.z,"[ t MAILING ADDRESS 230 E NELSON ROAD cnv ALLYN STATE WA ZIP 98524 sITEADDRESS 230 E NELSON ROAD-ALLYN CITY TAX PARCEL NUMBER 1 2 2 2 9 - 4 3 - 0 0 0 2 0 PROPOSED DRAINFIELD TYPE ® CONVENTIONALGRAVfDY D 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 V 0 Greater than 12" El 0 m Harstine Gravelly Sandy Loam 0 ❑ Greater than 18" Is Hoodsport Gravelly Sandy Loam 0 ❑ -Determined by: Shelton Gravelly Sandy Loam ❑I ,/ Pir/ Depth to hardpan 0 CI Sinclair Gravelly Sandy Loam Depth to mottling 0 0 Other 0 ❑ Both GV 2.SOIL TYPE: . 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 0 0 Z -Evidence of seasonal water table: Loamy Sand ❑, ❑ " Yes 0 � Sandy Loam I� No �� ''S'' Percent Gravel: -Curtain Drain required: O -Less than or equal to 35% 0 gel Yes ❑, 610:11e -Greater than 35% 0 ❑ - No LM 3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: z (5 Ln I Soils must be moderately well drained to well drained. I O Primary Drainfield must maintain 200'from down-gradi- rnp ent marine shorelines,surface waters,and wells. �_ Well Drained PZ/ Moderately Well Drained D0/ -Are increased horizontal setbacks met: Other 0 0 Yes Ni [� No ❑ 0 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 V 3%to 15% l gradient side of primary drainfield and 16%to 30% ❑ ❑ property boundary: Greater than 30% 0 0 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: parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recording: THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE. updated 3/2/2017 1 2184635 Mason County WA 07/13/2022 03:40:53 PM DECL eRecorded #177290 RecFee: $204.50 Pages: 2 ROBERT JOHNSON Return To Robert W.Johnson PLLC PO Box 1400 Shelton,WA 98584 Grantor(s): (1) Nina Southerland , (2) Jordan Turner Grantee(s): (1) PUBLIC Legal Description (1) Section 29, Township 22, Range 1 (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 12229-43-00020 - DECLARATION OF COVENANT FOR ON-SITE SEWAGE ATTENUATION ZONE I (We)the grantor(s) herein, am (are) the owners in fee simple of(an interest in)the described real estate situated in Mason County, State of Washington; hereby declare this covenant & place the same on record; to wit the described real estate on which the grantor(s) owns and operates an on-site sewage disposal system which has been granted a Class B State Waiver to reduce the Minimum Vertical Separation requirements and grantor(s) is (are) required to maintain a 50-foot horizontal attenuation zone down gradient of the on-site sewage system to facilitate treatment of the sewage effluent. It is the purpose of these grants and covenants to prevent certain practices hereinafter enumerated in the use of the grantor(s) land which might encumber the land set aside for further sewage treatment and disposal. NOW, THEREFORE, the grantor(s) agree(s) and covenant(s)that said grantor(s), his (her) (their) heirs, successors and assigns will not construct or install any trench, channel, ditch, road cut, utility chase, or other structure of excavation what would intercept or serve as a conduit for migrating ground water. Dated on this 11 th day of July , 20 22 • Page 1 of 2 Signature of Grantor(s): ,---- - (1) AVA46. AtttA/ s41),vL0-- , (2) 4itA.,_._ /I State of Washington ) County of Mason ) I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this r(_# day of \)tA. I i , 2022_, NiAr„ rl�n - ck ,3orcfa r n T`unev rsonally appeared before me, who is known to be signer of the above instrument, and acknowledged that he(she) (they) signed it. GIVEN under my hand and official seal the day and year last above written. ELIZABETH JOHNSON k?-e--t- •�1��'�� Notary Public Notary lic in an' or the State of Washington, State of Washington residing at .D ill Li ' License Number 163269 / My Commission Expires My commission expires: yr--V77 January 15,2025 Page 2 of 2 2184635 Page 2 of 2 07/13/2022 03:40:53 PM Mason County, WA