HomeMy WebLinkAboutWAI2023-00003 - WAI Health Waiver - 1/13/2023 /0`• • pl• qAik. 415 N. 6th STREET,SHELTON WA 98584
MASON COUNTY SHELTON: 360-427-9670, ext 400
'',Fa COMMUNITY SERVICES BELFAIR: 360-275-4467,ext.400
- -..� ,
-; _.._.- ��— 7 ELMA:360-482-5269,ext.400
`;J/t, - ,,' Building,Planning.Environmental Health,Community Health
�,,-ttunY," FAX:360-42 - t
= Application for Waiver or Appeal VS %1 \I
Amount Paid:IC(SS _ Receipt Number: 3A1\ 13 2023
WAI aoa3 - 000 03 By
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
36a0.16I0-'?ov-1
Name of Applicant '6Q .i .4 c- S.S Telephone -. t,-; 0 - -6-L1- vU 0
Mailing Address ( etc z. 3 EL-ic-=�3 c: � (S , S.1/41,1•
City A)--,b0-W- 1--i"CR__ State c I4 Zip C) ec .`i' `l
Parcel No. S 4 cl Q 4 - ` \ -- 9, J Q
Site Address i 6(.3 S \S'T rCR-, AA ii 4 6c.;v.s L.u S i-• • 5J fl/J
Subdivision Name and Lot i-v i 1 -S+-4 2. p A-i" 7� ‘ 4-l
PART 2: Nature of Waiver/Appeal
to Class B Reduce Vertical Separation 0 Food Sanitation Requirements
O Building Permit Review Policies 0 Group B Water System Regulations
❑ Location, WAC 246-272A-0210 0 Water Adequacy Requirements
i 0 Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 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
Applicant Signature: Date: IJZ5
Revised 8/21/20I7
This form may be scanned and available for public view on the Mason County Web site.
Page I of2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
c Appeal t'Waiver ❑ None required o Class A v'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
PRESSURE OSS.
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board 6a' Environmental Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN)
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN 2\4'1 Zfo' )
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: -15-W) Date: I (-7 17fS
PART 4: Determination of the Hearing Official
24- 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: 121—/ Date: �''- ?
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 2of2
i
OF' MASON COUNTY
y : COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH
4,4_moo��Jp Buf4trg.Pmminq@mI,o, entalI-MIth,CommunityHealth CLASS B WAIVER WORKSHEET
415 N.8TH STREET,BLDG 8,SHELTON WA 98584 (State and Local waiver forms required)
SHELTON:360-427-9670.EXT.400-BELFAIR:360-275-4487.EXT.400
ELMA:380.482.5269,EXT.400 -FAX:380.427-7798
APPLICANT NAME t �(+^/-N� `'1 J. ��'+(j ` S WANER PERMIT NUMBER WAI 2 ✓ —0 O O�
MAILING ADDRESS \' `'�` J �^L- '-&'"•`-�' t„) - - 1. �J G�
CITY `�0 �"(S C M A,� .�e STATE [A]4 t1 ZIP 9 (�c I" f
SITE ADDRESS 4�V .S t,�(S]--t— L_ `/�.`L1 A,0 0 t"�J L." �" '" r• CITY ��v3 ��'J,./J'.
TAX PARCEL NUMBER 31 C Q 4 — ,t1 Ck 0 0 ` O PROPOSED DRAINFIELD TYPE 0 CONVENTIONAL GRAVITY ,,CONVENTIONAL PRESSURE
1.SOIL SERIES: S.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 EP` El Greater than 12" EL
Harstine Gravelly Sandy Loam 0 0 Greater than 18" 0 F
Hoodsport Gravelly Sandy Loam ❑ ❑ -Determined by:
Shelton Gravelly Sandy Loam 0 0 Depth to hardpan 0 0
Sinclair Gravelly Sandy Loam 0 0 Depth to mottling 0 ❑
Other ❑ Both tEl-
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
iLoam.Gravel percent must be less than or equal to 35%. above restrictive layer,a curtain drain may be required
Medium Sand 0 ❑ Z -Evidence of seasonal water table:
Loamy Sand 0 ® ro Yes 0 0 ro
Sandy Loam a ❑ St No ®, Er z
Percent Gravel: ,�,{ 0 -Curtain Drain required: p
-Less than or equal to 35% I. of o Yes 0 q
-Greater than 35% ❑ ❑ 2 No a �3
3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: z
9,
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.
Well Drained ❑ ❑ S
Moderately Well Drained SI. St -Are increased horizontal setbacks met:
Other 0 0 Yes 72
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% Et
0 -Is there 50 ft or greater between the down
3%to 15% tStl- gradient side of primary drainfield and
16%to 30% 0 'Riproperty boundary: •
t�/
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 1 p Z
prior to design approval.The attenuation zone Is not to be used for the contruction of roads,decks,patios, AFN: Z 1 -l � I
parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Prna'or P.ecord!ng:
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIE'.V ON THE MASON COUNTY WEBSITE. updated 3/2/2017
• Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC
Effective Date: July I.2007 Revised April 2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations
Section I. (completed by applicant)
Name: (1) Local Health Department/District (2)
(see instructions)
Address:
_-- R tic �.LsWTt- •__.._.. Q_e s—is_......._... _.....-_.._.__..._._...._.._-___.._.....__.... _..—__._._.__._......._. __._._. ._.__---
Telephone: (3(QO) Uo•L? .. O V `8
S ignature:
Property Identification: (3)
Section II. (completed by applicant)
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
246-2272A— 0230 24" OF V/S FOR PRESSURE (OR) 12" OF V/S FOR PRESSURE OSS (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: Zlq 2 Co )
by health officer)
Section III. (completed ff'er)
Review Criteria: (8) Mitigation Measures an addition to those proposed): (9)
Comments/Conditions: (10)
Type of Waiver: (/1) ( ] Class A ,Class B I ] 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 14Approved /Granted— ubject to al comments,conditions and requirements noted in Se lions II and III.
Local Health Officer (13) Date: Vigi Z)
DOH 337-02I
2192634 MASON CO WA
01/10/2023 03 13 PM DECL
Return To HESS #183364 Rec Fee $204.50 Pages 2
!IIIIII1DII 1111111111111111 111111 1IIIIIIIIIIIII11111 I I IIIII 11E
(c GILL T S-U4-
(Z� (4cA 9
Grantor(s): (1) v-\-sf 55 , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) '3 L4.\
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) .3 1 q 0 4 - t 1 - C( U 0 (�
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 o pc , 20213.
Page 1 of 2
Signat re o Grantor(s): I Z,3
(1) , (2)
State of Washington
County of Mason
I, the undersigned, a f\;otary Public i and for the above named County and State, do hereby
certi that Qn this. (d day of , 20 <4,3,
I / 1 , perso Ily 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.
[Alf-)
NOTARY PUBLIC ; Notary Public i and for the s�tate of Washington,
State of Washington residing at /Hi/fi t/
MARIA RIVERA Commission#162227 My commission expires: / l/f,,
l '6a!
Commission Expires OCTOBER 15,2024
4
4
4
Page 2 of 2