HomeMy WebLinkAboutWAI2023-00075 - WAI Health Waiver - 7/28/2023 r '
415 N. 6th STREET,SHELTON WA 98584
MASON COUNTY SHELTON: 360-427-9670,ext 400
COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
ELMA: 360-482-5269, ext.400
• Building,Planning,Environmental Health,Community Health
FAX:360-427-7798
Ap lication for Waiver or Appeal
Amount Paid: AU. Receipt Number:
WAI Ula 414015
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 I C.)AALI S AOc.mo.* Telephone
Mailing Address 6/LI 11 t'L L
City d 1 Yi4101.4k State Ujo. Zip gq.501
Parcel No. S a 1 0 5 -- I, /// -- 0 l')n I.
Site Address_ C T7(Y..1rltf1 /�7 t?,l/ WA c '3SQa
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
I&( Class B Reduce Vertical Separation ❑ 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 ❑ Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determ i l -1
❑ Contractor Certification Requirements 0 Other ll U L5
(Installer, Pumper, O&M Specialists)
JUL 2 8 2023
Description of Waiver/Appeal (include justification, additional material may be attachec. . 1E3'
REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY
CLASS B WAIVER CHECKLIST
RECORDED DECLARATION OF ATTENUATION ZONE
Applicant Signature: _ Date: a� �cn1� 2oZ�j
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)
7 Appeal Waiver None required - Class A %/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 CONVENTIONA GRAVI OR
PRESSURE OSS.
4. Hearing Official:
❑ Board of Health 0 Health Officer
O Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board Environmental Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN)
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN 0 -2i eet )
Vd C1,0115 /30 4 /4'31af-c / We ite l SY til
6. I have received this waiver/appeal request. It is complete and mitigation required by the
state and local polio has been submitted.
(,,�-O 3 + - ...:3
Staff Signature: ,%//; w i� Date:
PART 4: Determina on of the Hearing Official
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:
❑ 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: 114V3r Date: 0(7%4
Revised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
F' MASON COUNTY MASON COUNTY PUBLIC HEALTH
--on n r COMMUNITY SERVICES
Building Planning.Environmental 1lealth,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
•
APR KANT NAME VI I CAVIL( S1IM^ytMN WAIVER PERMIT NUMBER WA
MAILING ADDRESS 6' ` I i' ' sc Q.
Cm ai {-pig s-ArE w,4- nP 9S.&0I
C..'SITE ADDRESS II Rf 11 w► /�`RA CITY �A;a1�
TAX PARCEL NUMBER 3 a 1 OS -51- Oc0/2 PROPOSED DRAINFIELD TYPE CONVENTIONAL GRAVITY 0 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 ❑ ❑ Greater than 12" 0 ❑❑
Harstine Gravelly Sandy Loam ❑ CI Greater than 18"
Hoodsport Gravelly Sandy Loam IL ❑ -Determined by:
Shelton Gravelly Sandy Loam ❑ ❑ Depth to hardpan RE ❑
Sinclair Gravelly Sandy Loam ❑ ❑ Depth to mottling ❑ ❑
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 ❑ ❑ -Evidence of seasonal water table:
Loamy Sand ❑ ❑ a Yes ❑ ❑
Sandy Loam E' ❑ 3- No t1 ❑ ---
Percent Gravel: ,�/ �o -Curtain Drain required: p
-Less than or equal to 35% L1p El -2 Yes ❑' a
-Greater than 35% El q No
3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS:
V7al N
Soils must be moderately well drained to well drained. O Primary Drainfield must maintain 200'from down-gradi- rt.
0
d ❑
ent marine shorelines,surface waters,and wells.
Well Drained sZ
Moderately Well Drained ❑ ❑ -Are increased horizontal setbacks met:
Other_ ❑ ❑ Yes ❑
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% ❑ ❑ -Is there 50 ft or greater between the down
3%to 15% Er ❑ 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 unbuildable V 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. Pool of Recording:
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE. updated 3/2/201;
4
1
•
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Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC
Effective Date: July I,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) LocaI Health Department/District (2)
law" !loewtaKer (see instructions) _-.-------------------._._ _._.._.._
Address:
6/y 1/'"`--g-i -- _
Telephone: (g o ) Saa -'$ot6
Signature:
Property Identification: (3) ACC4• ►i O S Cp04i 2
Section II. I (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: 2za2/476, )
Section III. I (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
--___-- 1/.410111 Do ilne 4
Comments/Conditions: (10)
Type of Waiver: (11) [ ]Class A 1>iplass 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. 1 (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 t all comments,conditions and requirre"me/noted in Sections II and III.
Local Health Officer (13) Date: 1
DOH 337-021 Page 26 of 32
2202166 MASON CO WA
Return To 09/15/2023 09:35 PM DECL
SHOEMRKER #190817 Rec Fee: $204.50 Pages: 2
NLi CAVN&I. SO- MA II II IIII I IIII IIIIIII IIII III II IIII 1011 l 1111ll 111 1111llt
0 q IA. - z viva
RECEIVED
Grantor(s): (1) M �(\AM.:� 'N -N(& J , (2)
Grantee(s): (1) PUBLIC }}
Legal Description (1) 1.�1 tk t\lf. h , �r1c ‘,-/A
(Abbreviated form: i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) ,) 1)— 1 05 51 coo 0 3._
S511. al i 3
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 Scpit.for , 20 17) .
!;ru) u.0tax 1u11 L Pagel oft
ill SEP 15 2023
By
Signature of Grantor( :
(1) "� ✓! , (2)
State of Washington
County of Mason )
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this k54`"day of ecry o - , 20 23 ,
�1\CA10,Q.1 S�f\nee on.c .Y.,ex personally appeared before me, who is known to be
signer 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.
KAELI E MCAULEY
Notary Public Not ry Public in and for the State of Washington,
State of Washington residing at S2(o u)c�2dar �� f�1na-ldbrt,+
License Number22037380
My Commission Expires My commission expires: c\ W 2o27
January 20,2027
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