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Home My WebLink AboutWAI2023-00066 - WAI Health Waiver - 6/14/2023 ,/J° try,, 415 N.6`h STREET,SHELTON WA 98584 MASON COUNTY SHELTON:360-427-9670,ext 400 •'l P COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 ''0', —��-- " ELMA: 360-482-5269,ext.400 ' Building,Planning,Environmental Health,Community Health EE Ilj A.N.ication for Waiver or A peal 1 M r] T Amount Paid: 5 Receipt Number: JUN 2 3 2023 ti WAI 2 o 3 OOa bfp rbe 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 Name of Applicant MACKENZIE STEVENS Telephone 3604904205 Mailing Address 141 SE COOK PLANT FARM RD City SHELTON State WA Zip 98584 Parcel No. 22032-24-90010 Site Address 7590 LYNCH RD SHELTON, WA Subdivision Name and Lot SP#3030 - LOT 1 PART 2: Nature of Waiver/Appeal IV 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 ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines O 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 PRESSURE OSS CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE Applicant Signature: I Date: 5/19/23 IRevised 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 +'Waiver I None required [ . Class A %/Class B I 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 O Pollution Control hearing Board 0 Public Health Director O Certified Contractor Review Board 6' Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST (MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN 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° (Z 3 1 PART 4: Determination of the Hearing Official 64 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: 4 ❑ 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: 7/17" Date: O/ " G7/21 Revised A/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 I . MASON COUNTYIII 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 MACKENZIE STEVENS WAIVER PERMIT NUMBER WAI MAILING ADDRESS 141 SE COOK PLANT FARM RD CITY SHELTON STATE WA ZIP 98584 SITE ADDRESS 7590 LYNCH RD CRY SHELTON, WA TAX PARCEL NUMBER 22032-24-90010 PROPOSED DRAINFIELD TYPE 0 CONVENTIONAL GRAVITY KCONVENTIONAL 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 ❑� NJ Greater than 12" ❑ I Harstine Gravelly Sandy Loam 0 ❑ Greater than 18" 0 ❑ Hoodsport Gravelly Sandy Loam ❑ ❑ -Determined by: Shelton Gravelly Sandy Loam ❑ ❑ Depth to hardpan ❑ 0 Sinclair Gravelly Sandy Loam ❑ 0 Depth to mottling ❑ ❑ Other ❑ El Both ❑✓ IIV 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 Z -Evidence of seasonal water table: Loamy Sand ❑ 0 2 Yes 0 0 Sandy Loam Cl L7 No ❑� Percent Gravel: -Curtain Drain required: O ❑ -Less than or equal to 35o/u n Yes ❑ El 4:3 -Greater than 35% ❑ 0 q No 0 IEK9j. ro FO 3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: Soils must be moderately well drained to well drained. O Primary Drainfield must maintain 200'from down-gradi- F, ent marine shorelines,surface waters,and wells. 0 Well Drained ❑ ❑ Moderately Well Drained 0 Er -Are increased horizontal setbacks met: Other 0 ❑ Yes 0 UK- No ❑ ❑ 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% ❑ El,— -Is there 50 ft or greater between the down 3%to 15% ❑ �JQ gradient side of primary drainfield and 16%to 30% ❑ ❑ property boundary: ,_., Greater than 30% El Yes 0 21 No ❑ 0 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: vl "` 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 • 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. , (completed by applicant) Name: (1) MACKENZIE STEVENS Local Health Department/District (2) (see instructions) Address: 141 SE COOK PLANT FARM RD SHELTON WA 98584 Telephone: ( )360-490-4205 Signature: thslas Property Identification: (3) 7590 LYNCH RD, SHELTON 22032-24-90010 Section II. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A— 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: $((r) ) 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 44-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 W. 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 ubject t comments,conditions and requirements noted in Sections II and III. Local Health Officer (13) Date: �/) DOH 337-021 Page 26 of 32 2198693 MASON CO WA TIENI 06/23/2023 11:30 AM DECL JUN 2 7 2023 RECEIVED 111.1 JUN 2 3 2023 Return to: `� MACKENZIE STEVENS 141 SE COOK PLANT FARM RD By • SHELTON WA 98584 DECLARATION OF COVENANT FOR ON-SITE SEWAGE ArlENUATION ZONE I(We)the undersigned grantors hereby declare this covenant and place the same on record. I(We)the grantor(s)herein,am(arc)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 02W 20N 32 Subdivision Division Lot Range Township Section and having the Tax Parcel Number of: 22032-24-90010 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 day ,2023 . Sig Signature State of Washington ) • County of Mason I the undersign ,a Notary Public in and for the above named County and State,do hereby certify that on this a3 day of 209,3, tvetQcktrrut 34-e enS personally appeared before me, • who is known to be sign 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. 0111111/4/,, RI q� Notary Pu lie in and fore State o}fW g • `•`` •pJ•�••••��`� i'' residing at MG(.SCY1 Lo '1iUi ' I • My commission expires: t j--15 -2_—i Z . NOrit ^{� • �� Y„till O • p •�N: VBLIC J►• • 4.es esotagot*/ �AHIIIIIIIHI1� i