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Home My WebLink AboutWAI2022-00135 - WAI Health Waiver - 11/14/2022 l DocuSign Envelope ID:072E80C7-DD52-46FA-A904-FOCA7DAC63AD r /''`'", t y'. 415 N.6'h STREET,SHELTON WA 98584 MASON COUNTY SHELTON:360-427-9670,ext 400 .l 1' COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 �r ✓� ELMA:360-482-5269,ext.400 ``�.% Building,Planning,Environmental Health,Community Health , FAX:360-427-7798 Application for Waiver or Appeal Amount Paid: '`7 S $ Receipt Number: IL WAl eLlt_ O b 1 IT 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 Collin R Russell Telephone 360-250-8388 Mailing Address 310 NE Kissin Tree Lane City Tahuya State WA Zip 98588 Parcel No. 3 2 3 3 4 -- 2 4_ 0 0 0 0 0 Site Address 310 NE Kissin Tree Lane Tahuya, WA 98588 Subdivision Name and Lot NA PART 2: Nature of Waiver/Appeal 12' Class B Reduce Vertical Separation 0 Food Sanitation Requirements O Building Permit Review Policies 0 Group B Water System Regulations O Location,WAC 246-272A-0210 0 Water Adequacy Requirements O Holding Tank WAC 246-272A-0240 ❑ 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 DocuSignedd by:�,,��(� Applicant Signature: [C° n�',` (1'A 11/14/2022 PP 9 as z„ Date: 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) r Appeal /Waiver None required 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 0 Health Officer 0 Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board 63' Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN ZZOO5 , ) 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local poi. has been submitted. Staff Signature: Date: 7/3// 'O 7 PART 4: Determination of the Hearing Official L ' 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: 7/70? Revised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 } MASON COUNTY 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 CRYSTAL MATTSON WAIVER PERMIT NUMBER WAI MAILING ADDRESS PO BOX 867 CITY MCKENNA SINE WA ,I, 98558 SITE ADDRESS 310 NE KISSIN TREE LN, TAHUYA, WA 98588 CITY TAX PARCEL NUMBER 323342400000 PROPOSED DRAIN FIELD TYPE Ei CONVENTIONAL GRAVITY' a 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 ❑� N Greater than 12" CI 1 Harstine Gravelly Sandy Loam ❑ Greater than 18" ❑ ❑ Hoodsport Gravelly Sandy Loam ❑ ❑ -Determined by: Shelton Gravelly Sandy Loam ❑ 0 Depth to hardpan ❑✓ Sinclair Gravelly Sandy Loam ❑ 0 Depth to mottling 0 Other 0 0 Both 0 0 2.SOIL TYPE: 6.WATER TABLE LEVEL: Soil types must be Medium Sand,Loamy Sand,or Sandyl 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 0 _ -Evidence of seasonal water table: Loamy Sand El en Yes 0 a Sandy Loam ❑✓ No 0 ❑• s Percent Gravel: -Curtain Drain required: p -Less than or equal to 35% 0 0 o Yes 0 0 tO o3 Greater than 35% ❑ ❑ No 0 TO ro 3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: z ris c Soils must be moderately well drained to well drained. 0 Primary Drainfield must maintain 200'from down-gradi- rti zent marine shorelines,surface waters,and wells. 0 Well Drained ❑ ❑ `-c Moderately Well Drained ❑✓ M. -Are increased horizontal setbacks met: r�5 Other ❑ Yes 0LU 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% 0 @ -Is there 50 ft or greater between the down 3%to 15% 0 gradient side of primary drainfield and 16%to 30% ❑ ❑ property boundary: Greater than 30% 0 0 Yes 0 Ni No ❑ ❑ The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable Z Zoo S 20 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 MAYBE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE. updated 3'2/201 7 • 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) Local Health Department/District (2) CRYSTAL MATTSON see lnstrllctlons) Address: PO BOX 867 MCKENNA WA 98558 Telephone: ) 253-228-7462 Sign lure: � at I 1P A Y0" — Property Identification: (3) J 310 NE KISSIN TREE LN,TAHUYA, WA 98588 323342400000 Section II. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sou t: (6) -------------- ----- 246-272A— 0230 24" OF V/S FOR PRESSURE (OR 12" OF jaS FOR PRE$SI I13g 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: 2ZOd S20 ) Section III. I (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: 10 dos 7 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. 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 OLApproved/Granted—Subject to all comments,conditions and requirements n ted in S ctions II and III. Local Health Officer (13) Date: 7 7/ 2-7 DOH 337-021 Page 26 of 32