HomeMy WebLinkAboutWAI2023-00070 - WAI Health Waiver - 6/27/2023 (2) / \ MASON COUNTY 415 N.6th STREET,SHELTON WA 98584
SHELTON:360-427-9670, ext 400
COMMUNITY
SERVICES BELFAIR:360-275-4467, ext.400
j Building,Planning,Environmental Health,Community Health ELMA:360 482-5269,ext.400
FAX:360-427-7798
Application for Waiver or Appeal
Amount Paid: a.q Receipt Number: 2 — r, T __
!1 i��+� t i!1
WAI �-'� - C00-1. JUN 2 7 /jI/
Instructions: 1(113 1
1y .:;iroTnpl ai 1 and 2 tip detehtilr at�iitt:can be made i60*4ese pare II
2 F may bye billed for waivers and;ape ,based o t ie l nuironme>tat I tealth F ee edule ...:::.:.`
:::3:: Submit t ompleted application. iiitf attachments to Masson County Public.Health for rieview
PART 1, Applicant & Parcel Information
t
Name of Applicant \rc; t„1, S\)1� Telephone .`Z�
Mailing Address c .\095, ( " C , S , "\
City —3Co. \Ql State\ 1 , Zip0\ \CV
Parcel No. 3 c _ _ C\ 0 0 a_
Site Address eo,c-s\A \1\10\c_ V_A\
Subdivision Name and Lot
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
❑ Location, WAC 246-272A-0210 0 Water Adequacy Requirements
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 PRESSURE OSS
CLASS B WAIVER CHECKLIST
RECORDED DECLARATION OF ATTENUATION ZONE
Q \c'
Applicant Signature: Date: . `
( : l�
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)
LI Appeal 'Waiver ❑ None required c Class A tIClass B Li 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 GRAD(-R
PRESSURE OSS.
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public 4-leaith Director
❑ Certified Contractor Review Board Il Environmental Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN)
c 15
/ ,
2.
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN 22
010 (-( Z
6. I have received this waiver/appeal request. It is complete and mitigation required by the
state and local p ' y has been submitted.
Date: j� ' 2
Staff Signature: 66 (^)t\M'er 3
PART 4: Determi tion of the Hearing Official
I - 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: 17 j
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2
MI
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MASON COUNTY MASON COUNTY PUBLIC HEALTH
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COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Hcalth CLASS B WAIVER WORKSHEET
415 N.6TH STREET,BLDG 8,SHELTON WA98584 (State and Local waiver forms required)
SHELTON:360-427-9670,EXT.400-BELFAIR:360-275-4467,EXT.400
d ELMA 3604825269,EXT.400- FAX:360-427-7798
APPLICANT NAME \ Se
) ` '\ WAIVER PERM NUMBER WA I
MAILING ADDRESS \ C ? C
CITY .. e(-�l r\ \c\l VVV STATE Y Vi:\ 21P , `\
SITEA00RESS • Jl. ..�\\\�Av CITY .�. 1\\` ,,,f;\\\-
�,
TAX PARCEL NUMBER �, /j
\ Y J \ � t� PROPOSED DRAIN TYPE � CONVENTIONAL GHAVfrY CONVENTIONAL PRESSURE
1.SOIL SERIES: S.VERTICAL SEPARATION: )8(
CONVENTIONAL
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 El : ! _^,; k Greater than 12"
Harstine Gravelly Sandy Loam 0 '"r.; .
, Greater than 18" ❑ •i?::' it.
Hoodsport GravellySandyLoams;• rj,, ,
p ; -Determined by: , •c.".z
Shelton Gravelly Sandy Loam ❑ ' .:-
f.. Depth to hardpan "tki'
Sinclai Gravell SandyLoam. ❑ - .i;;; '.+4 0 • ,..
v Depth to mottling �-
OtherOC> �` {1 �F+ 4-, Both ❑
2.SOIL TYPE: �' 6.WATER TABLE LEVEL: .x;
Soil es must be Medium Sand,LoamySand,or Sandy `'�'r=�'r"S If test holes show evidence of a seasonal water table
types >;Y#
Loam.Gravel percent must be less than or equal to 35%. ; >;.:>'c* above restrictive layer,a curtain drain may be required • , ,..
Medium Sand 0 ': :, -Evidence of seasonal water table: =,r-.:
Loamy Sand 0 *= 'l .
, Yes
Sandy Loam `v;'4: No . ry;t:
fpk ,,N .Percent Gravel: `5 a- -Curtain Drain required: x.
-Less than or equal to 35% 'ar:::= Yes 0 .• .:'.
-Greater than 35% 'FA No g y';•i;r
3.SOiL DRAINAGE: 7.HORIZONTAL SETBACKS:
r
t.
Solis must be moderately well drained to well drained. Primary Drainfield must maintain 200'from down-gradi- 5,I
'' ent marine shorelines,surface waters,and wells. �,
Well Drained 0 �. y`
Moderately Well Drained "i 1 -Are increased horizontal setbacks met:
Other_ 0 `, Yes •
p•,:. ;. No 0 zti...
4.DRAINFIELD SLOPE: of• +/ •.>'y
'.i. 8.ATTENUATION ZONE r---.0;,. r`
Slopes must be between 3%to 30%. ._;? 'it?: ?p i v^' '
Gravity is only allowed on slopes from 3%to 15%. ,:x e.z A 50 foot horizontal attenuation zone is required 'x4to- `
Pressure Is allowed on 3%to 30%. ;; F r:„ L down-gradient of the primary drainfield. c<r.'s
Less than 3% 0 s'hi ?'':;; -Is there S0 ft or greater between the down } ,;
3%to 1596 . 0 :.3 •;a�mz gradient side of primary drainfieid and �,. r`
16%to 30% 2....q,
�.4 ^ property boundary: 's'z
,r- L
Greater than 30% ❑ �c ;,'°¢ttt. Yes iv...
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: 422 DO 4 2 `1
parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recording: J
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE. updated 3/2/2017
t
Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC I
Effective Date: July 1,2007 Revised April 2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations
(completed by applicant)
,,m,:_Y s• pai Hea t1i ' .,.:. .
S ct (2)
'Name: (1) � �-�x �,,Y ,,�,.•�..•'... ,
_ 7,.„1,,,,s,,,
. .
. „v.,...
Address: 1' - (A.. a4 , , iti - \ r ��� �G{ i
v c, -....&
e Cs----.\- C-C- i NA ___%\°\b--.__ .:.:',i4Af';.:z4i:..-.,..4.::w:
2 .gt3;i r
...__.....�.--�_ 1 ~.@�S
Telephone: �L, 4 `'
� �
Signature: .y. ,
.''''>.... . iift
Property Identification: (3)��-- -
(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 JOR)
Subsection: TABLE VI 3 " S roil GRAVITY 18" or V/S FOR GRAVI-TY OSC
Justification(mitigation measures to be provided): (7) COMPLETED CLASS B WAIVER CHECKLIST ATTACHED,
(OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN.
ZONE() FN: , . )
�t '.w (completed by health officer)
3:1�e��:�e
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
_ ____p.vr):e-
2.2.901s.2_
. . _ .
Comments/Conditions: (10)
Type of Waiver: (11) [ ]Class A [ lass B [ ]Class C—Request DOH review before granting? Yes— No
Yes No If
needed, are agreements, easements, etc.properly filed? Yes — No
Neighbor Notification: (12) Required? — _
S l (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—Subject to all comments,conditions and requirements note in Sections II and III.
Local Health Officer (13) Date: 76 Z
DOH 337-021
2200824 MASON CO WA
08/15/2023 02:46 PM DECL
Return To SUN #R189782 Rec Fee: $204.50 Pages: 2
III II I II II I I I I II I III I I II I II I I I I I IIII IIII III
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Se c \r•��°\�\°1� Ip C C� [ 0 W
AUG 15 2023
TO
ay
Grantor(s): , (2) ._
Grantee(s): (1) PUBLIC
Legal Description (1)
(Abbreviated form:i.e. lot, block, pa or section, township, range)
Assessor's Tax Parcel: (1) \ - \ 1 - l C)
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 of , 20
•
•
Page 1 of 2
Signature of Gran or(s):
(1) , (2)
State of Washington . )
County of-Masai; t 4r, )
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certity that on this 1 j day of (.1 '' , 2023 ,
cit(vvi(-;l 'tL n personally appeared before me, who is known to be
signer of-the above instrument, and acknowledge at he;(she) (they) signed it.
GIVEN under my hand and official seal the da and year ve written.
Notary Public
State of Washington
REBECCA A CRIQUI ry Public in and for the Sta hington,
COMMISSION#64165 residing at D /t.e5 (MY COMMISSION EXPIRES M ission eX ires: 2 ^a`g•� .2'^7
February 28,2027 y comm p
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