HomeMy WebLinkAboutWAI2022-00141 - WAI Health Waiver - 11/22/2022 415 N.6th STREET,SHELTON WA 98584
!/ :i.\ MASON COUNTY SHELTON:360-427-9670,ext 400
1111"1` 1 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: ,12�S Receipt Number: 20 Z2, — Q6133---
WAI 2-022 - 141
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 & Parcelar Information
Name of Applicant be11 0011119c Telephone 360 6i9 /So 6
Mailing Address P 0- Qb' l j tt
City &,\ \f State W& Zip q.%SaZ
Parcel No. 3 a a (9 - a 0 — () L( Q 8 d �)t d ! �
Site Address E /i Gsot1 lake. Rd GCa littO
Subdivision Name and Lot
Aft t/‘) P 4/ML -32J-2-(2 23k— °c'i
PART 2: Nature of Waiver/Appeal
12/ 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
❑ Mason County Onsite Standards ❑ 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 . . .
CLASS B WAIVER CHECKLIST
RECORDED DECLARATION OF ATTENUATION ZONE
Applicant Signature: Date: )S A/Wv 2dZ7i
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 1 of2
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) i Local Health Department/District (2)
S ) ;Yon ncci — (see instructions)
Address:
P o . go* /
Telephone: (360) 6 $q /row,
Signature: �,i�✓`�ZG�"' 1 41(/1
Property Identification. (3) Para( ## ?, J( b- a 0- 011 oo 0 __—.—
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: 2—L syg7 )
Section In (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Conditions: (10)
Type of Waiver: (11) [ ] Class A }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 b1.1.Approved /Granted—Subject to all comments,conditions and requirements noted in Sections H and u1.
Local Health Officer (13) Date: 1/1-4/Z3
DOH 337-021 Page 26 of 32
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
o Appeal VWaiver o None required o Class A 6d'CIass B o 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 CONVENTIONA RAVI
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board ' Environmen #�
5. Mitigating Factors: •
CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS UTLINED WITHIN)
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZO E (AFN o21 g5 Y7
6. I have received this waiver/appeal request. It is complete and mitigation required by the
state and local p ' has been submitted.
Staff Signature: `'U 1(A Date: ( ��
PART 4: Determination of the Hearing Official
F.-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: Date: 0-1
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
al. '' MASON COUNTY COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH
Bonding.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 gar 3-JL l\fls S�1 WAVER PERMIT NUMBER WAI
AR M3NG ADDRESS Q o. gal, I 1 7-1 ', f jj Q Q'
CITY !](;�•�.L( STATE W 71 /� zip Q D 5 O
srrE ADDRESS I&S S. t �� 4 art' lJ 1 eid3e UIC7n)
TAX PARCEL NUMBER 2 I , b-,2D-()L/oo° PROPOSED DRAINFIELD TYPE CONVENTIONAL GRAVITY 0 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 l2"for pressure.
Alderwood Gravelly Sandy Loam ❑ ❑ Greater than 12" ❑/ El
Harstine Gravelly Sandy Loam El El Greater than 18" Q
Hoodsport Gravelly Sandy Loam ❑ ❑ -Determined by:
Shelton Gravelly Sandy Loam d Depth to hardpan
Sinclair Gravelly Sandy Loam 0 ❑ Depth to mottling 0 ❑
Other ❑ ❑ Both ❑ ❑
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 C,/ ❑ - -Evidence of seasonal water table:
Loamy Sand LM a Yes ❑, ❑
[J
Sandy Loam _........ ❑ ❑ ? o No --
Percent Gravel: ,, -Curtain Drain required: C
-Less than or equal to 35% d ❑ fl Yes rn
-Greater than 35% LI ❑ No......._...._.__..........._.._....._..__.._....._..._.._...._............ ❑ o
ro �2
3. SOIL DRAINAGE: 7.HORIZONTAL SETBACKS:
N
I Soils must be moderately well drained to well drained. O Primary Drainfield must maintain 200'from down-gradi- rti
�/ ent marine shorelines,surface waters,and wells.
Well Drained
LYJ *-
Moderately Well Drained ❑ -Are increased horizontal setbacks met:
1 (Nc
Other ❑ ❑ Yes _ _.._...__..._ _....._._.._..........
No LI LI
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
3%to 15% L. {T] gradient side of primary drainfield and
16%to 30% ❑ (� property boundary:
Greater than 30% CI Yes ❑
No ❑ al
The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuilda r le / ,`�
prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: J `i /
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 WEBSnL •-.,•3/2/2017
2195447 MASON CO WA
03/31/2023 10:37 AM DECL
11111111111111111111 IIII 1111111111111111111II III IIII I11111111 HIages: 1
Return to:
4111 GS IB
DECLARATION OF COVENANT FOR ON-SITE SEWAGE ATTENUATION ZONE
I (We)the undersigned grantors hereby declare this covenant and place the same on record.
I (We)the grantor(s)herein,am(are)the owners in fee simple of(an interest in)the following described real estate
situated in Mason County,State of Washington;to wit
(Division and Lot Number or Range/Township/Section Number. Note: Range,township,section numbers are
the 1'5 digits of the parcel number)
OR 3%! (2-11V 2-40
Subdivision Division Lot Range Township Section
and having the Tax Parcel Number of:3 4 --g d O A_
on which the grantor(s)owns and operates an on-site sewage disposal system which has been granted a Class B
Waiver to reduce 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 /6 y of V ,20 43.
c
Signat Signature
State of Washington )
County of Mason )
I,the undersignecLa Not ry Public in and for the above named County and State,do hereby certify that on this
/rr4 day of Roe< ,20 0 ,'TES Oa oid?1>, own NTAP,4"Arips personally appeared before me,
who is known to be signer of the above instrument,and acknoCvledged that he(she)(they)signed it.
GIVEN under my hand and official seal the day and year last above written.
Notary Public Nota Public in and for lie Ste of1 g
Washin ton
State of Washington residing at ?a,r t rc o.rf
' MARK LAMBERT My commission expires: To•,aefry 8 2v?-6
COMM.EXP.JAN.08.2028
COMM.NO.148385