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HomeMy WebLinkAboutWAI2022-00018 - WAI General - 2/22/2022 415 N.6th STREET,SHELTON WA 98584 MASON COUNTY SHELTON:360-427-9670,ext 400 I � COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 ELMA:360-482-5269,ext.400 Building.Planning,Environmental Health,Community Health FAX:360-427-7798 Application for Waiver or Appeal Amount Paid: 11 qr Receipt Number: • WAI coo te 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 \ C �`C1 Y v G 00 1Ck Telephone(*),YAC\O— ) Mailing Address \� cv\Ck Cr ,Y1 r`l� City "J\C' cs Y1 State \1\5 Zip C\5\7:aHA\ Parcel No. Q 0 (n - \ - 0 Site Address . q Lk\m (C , Subdivision Name and Lot 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 re . , , El Mason County Onsite Standards ❑ Departmental Determination p_ 31 ❑ Contractor Certification Requirements 0 Other £ j e..:6, (Installer, Pumper, O&M Specialists) � �' l y 2 �? '�, Description of Waiver/Appeal (include justification, additional material may be attached.): i REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY OR PRESSURE OSS ---e- CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE \ \ . ems Applicant Signature: \- 11 \-,' - '\A Dat Revised 8/21/2017 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 Determination Required: Type of Onsite Waiver(if applicable) ❑ Appeal v'Waiver ❑ None required o Class A /Class B n 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 9R- PRESOURE OSS. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board IEY Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST (MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN ' '°\ `k kC)1 ) 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: 3 f(t.,''Yb1')' PART 4: Determination of the Hearing Official 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: 37R/(02 Health Official Signature: � � Date: 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 April2017 On-Site Sewage Systems(Chapter 246-272A WAC) Request for Waiver from State Regulations Section I. (completed by applicant) Name: (I) Local Health Department/.District:(2) � � � ® see instruction_ �._ — Address: '' . ( ' 1C.. _._ 1.:1 H Co-- �-__±�. _P i .s., fi-kc_-. tad.. - - --- - .fit- .. 1 w ter S %r \\ _ Telephone'O Signature ' Property Identification; (3) F _______ __ _ s -C___�� •....._ $ -- T __. Section II. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246 272A— 0230 2 ,'or vie ) 12"or VIO roR PRCO&URC OM (OR). 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: 31 y`i C. Section III. (completed by health officer) Review Criteria:.(8) Miti:X tion Measures(in addition to those proposed): (9) Comments/Conditions: (l0) Type of Waiver: (11) [ 1 Class A _ 8Class B [ 1 Class C—Request DOH.review he ore.granting? Yes No Nei hborNotification; (12) Required? Yes No. If needed,are agreements,easements,etc.properly filed? Yes No Section IV. l (completed by health office 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 rotection at least equal to tb rovided by this chapter WAC. [ ];Denied [ Approved/ a'a ed bject to all comments,conditions and requirement note in Sections H and III. Local Health Officer (13) .._. Date: DOH 337-021 ,111"7": MASON COUNTY MASON COUNTY PUBLIC HEALTH A , *=I COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health CLASS B WAIVER WORKSHEET 415 N.6TH STREET,BLDG 6,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 `` ` 1 `' t y U\A, WA ER PERMIT NUMBER WAI /�' -0 U c \ D APPLICANT NAME �� � 1� /�Q�1 `` (� MAILING ADDRESS \ CIVIL \-1 C` are STATE I ZIP SITE ADDRESS � /.� /�v CITY //. TAX PARCEL NUMBER ? O o to, - 3 4, t Q V c) 3 PROPOSED DRAINFIELDTYPE CONVENTIONAL GRAVITY ❑ 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"tor pressure. Alderwood Gravelly Sandy Loam .2'" Greater than 12° 0 0 Harstine Gravelly Sandy Loam 0 0 Greater han 18" ® � Hoodsport Gravelly Sandy Loam 0 0 -Deter mined by: Shelton Gravelly Sandy Loam 0 0 Depth t4 hardpan..._.............................. El la". Sinclair Gravelly Sandy Loam 0 ❑ Depth tli mottling 0 0 Other 0 0 Both 0 0 2.SOIL TYPE: 6.WATER TABLE LEVEL: Soil types must be Medium Sand,Loamy Sand,or Sandy If to I holes show evidence of a seasonal water table Loam.Gravel percent must be less than or equal to 35%. abov restrictive layer,a curtain drain may be required Medium Sand 0 0 s -Evict ce of seasonal water table. Loamy Sand 0 ,❑/Q Yes 0 ❑ a Sandy Loam ® ,60 3- No a ._ Percent Gravel: �a -Curtain Drain required: D -Less than or equal to 35% Nil 2" Yes 0 0 -Greater than 35% 0 ❑ 8 ®No -Ell. ro 3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: rb c I Soils must be moderately well drained to well drained. I O Primary Drainfield must maintain 200'from down-gradi- ro ent marine shorelines,surface waters,and wells. 0 scz Well Drained 0 0 Moderately Well Drained ® -Are increased horizontal setbacks met: Other ❑ 0 Yes No 0 0 4.DRAIN FIELD 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% ❑ 0 -Is there 50 ft or greater between the down 3%to 15% NI .r gradient side of primary drainfieid and 16%to 30% 0 0 property boundary: Greater than 30% 0 0 Yes ® `. No 0 ❑ The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable X prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: ? I t L: 07 parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recording: THIS FORM MAYBE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE. updated 3/2/2017 2184407 MASON CO WA { 07/08/2022 03:00 PM DECL GOULD #177104 Rec Fee: $204.50 Pages: 2 IIIIIII IIIIII III lit IIIIIII IIIIII IIII IIII IIIII IIIII IIIIIII III IIIII IIII IIII Return To ' 2x�k E V owof 130\ E. CY1a&OtneoCrek.�.�t�d Grantor(s): (1) 1 .eY V 011;211.\ri , (2) Grantee(s): (1) PUBLIC Legal Description (1) 1 ok 3 SS# 2olSe• SW U - 20-2- (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1), ."2- C) U 1p - o c) 0 3 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_�day of J IL( y , 2022 Page 1of2 JUL 0 8 2022 - By Signatu/ - (1) ;, 9Gz lL ' (2) State of Washington ) County of Mason ) I, the undersigned, a Notary Public ir and for the above named County and State, do hereby certify that on thi % day of �t l/ , 20'Z"L , .1-r )± IOu,ld personally appeared before me, who is known to be signer of the above instrument, and acknowledged that he (she) (they) signed it. GIVEN under Vitt wl�,and official seal the d nd year last abo rit n. ©�oco'00-20?4N�d'''; Notary Publica 'd for the tate of Washington, _ NOTARY _ residing at V tU n Y t ••r. Pusuc co. ' My commission expires: 7j �` umb 'C, • ,///// WA S I•,���\ Page 2 of 2