HomeMy WebLinkAboutWAI Health Waiver - 6/22/2023 .n.rplir
^e. COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH
.'. &Aiding Nanning.Envinnmental Heald,.Co munity Health CLASS B WAIVER WORKSHEET
. MASON COUNTY
415 N.6TH STREET BLDG 8.SHELTON WA 98584 (State and Local waiver forms required)
SHELTON'360427-9670.EXT.400 -BELFAIR'360-2754467.EXT 400
ELMA 360482-5269.EXT.400 FAX'360-427-7798
APPLICANT NAME I La V r r L r v L-� l, WAWA PRINT NUMBER WAI
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MAILING ADDRESS ` ��U > 7(.., /], 7J
CITY C)I c-s-ik G C,�
. —G STATE —v' `� P 9 r } S' 5
ASITE ADDRESS L "1 �.'Jru r� L OTT Ctil e k ,-{i!,.
TAX PARCEL NUMBER 7 2U� -. 7(-D-- C)c ZU PROPC6ED DRAMRELDTYPE ISITONVENTIONAL 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'for pressure.
Alderwood Gravelly Sandy Loam.........___.. M 0 Greater than 12" - __.__ 0 0
Harstine Gravelly Sandy Loam _ _ ❑ ❑ Greater than 18'___.._. _..__.._.'Ia ❑
Hoodsport Gravelly Sandy Loam _.... .... ❑ 0 -Determined by:
Shelton Gravelly Sandy Loam_._ _ 0 ❑ Depth to hardpan________ ❑ 0
Sinclair Gravelly Sandy Loam..___ 0 ❑ Depth to mottling_._ . 0 0
Other ---❑ 0 Both..- ........__. __-. _ ____.... I� ❑
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 3596. above restrictive layer,a curtain drain may be required
Medium Sand ._____ __. 0 0 -Evidence of seasonal water table:
LoamySand .-..._....._..._.__._.._.—._..._...._...._.❑ 0 2 Yes_.._...._ ..__._.____..__._._.___._._.._._. ❑ 0 is
SandyLoam.._............._..._.___. _._ ._ ® 0 i No.._...._._._.__....___.__w_ ._............._..........® ❑ S
Percent Gravel: curtain Drain required: p
-Less than or equal to 35%...._.._...._.._......__...._.. ISt ❑ a Yes __ _.___ .__.. .. _. . 0 0 -
-Greater than 35%....__...._...._........_..._ _ . ...❑ 0 §. No 13 0 3
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3.SOIL DRAINAGE: c 7.HORIZONTAL SETBACKS: z
F,rt, C
Soils must be moderately well drained to well drained. 0 Primary Drainfield must maintain 200'from down-gradi- F.ent marine shorelines,surface waters,and wells. 0
sZ-
Well Drained.................._.._ — 0 ❑ ``
Moderately Well Drained....._ __. __ ,IR 0 -Are increased horizontal setbacks :
Other _— ❑ 0 Yes ®- ❑
No ❑ 0
4.DRAINFIELD SLOPE:
8.ATTENUATION ZONE
Slopes must be between 3%to 3096.
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% _..._......_... ._ _._ ___ fir 0 gradient side of primary drainfield and
16%to 30%.__......._____ ❑ ❑ property boundary:
Greater than 30%..__.._.......___.___ ___. ❑ ❑ Yes......_..__._._.. . '' ❑
No.____ _ ___.._..._....__.._ ❑ ❑
The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbulldable ^ ( �
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 ONTHE MASON GOWN WEBSI E_ updated 3/2/2017
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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) Local Health Department/District (2)
r f C I G 1-6 J'ex (see instructions)
Address: e 0 n /
O /U S-1.
Telephone: (? ) (� �OQ
Signature:
Property Identi do : (3) i Gc.L.
0 ,c 1 e-1-Z ,,-1 S •l 1/4
-!'l,- S V V�/ o f l V\) t13 'Al S c I 1- Z C L i, 2 Z W>-sc•t (C
2.7C1 _ 7(f _ OO62o
Section II. l (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 ci66" OF V/S FOR GRAVID 18" OF V/S FOR GRAVI O
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,tgv7 5 )
Section III. l (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Conditions: (10)
Type of Waiver: (11) I ]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. 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 [I }-Approved/Granted—Subjec all comments,conditions and requirements oted in SS tions II and III.
Local Health Officer (13) Date: o / L
DOH 337-021