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Home My WebLink AboutWAI2024-00004 - WAI Health Waiver - 1/8/2024 COUNTY 415 N.6th STREET,SHELTON WA 98584 /_ MASON COU�tiv 1 i SHELTON:360-427-9670,ext 400 • rpoi r COMMUNITY SERVICES BELFAIR:360-275-4467, ext.400 - - ELMA: 60-482-5269,ext.400 Building.Planning Environmental Health.Community Health FAX:360-427-7798 Application for Waiver or Appeal JAN 0 8 2024 Amount Paid: Receipt Number: ' 11 ay WAI O O2Li - o0004 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 /GA;BA e'asi Telephone 360 7 SI -7 9a Mailing Address /Z-'( W g u.„-‹; a City SPO 14.- State Wp,L Zip gQ(1.6( Parcel No. a a a a. 3 - 7 - 7 - 9 0 o b Site Address 3� C LI Auk . I l.;r Subdivision Name and Lot PART 2: Nature of Waiver/Appeal IS( 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 ❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations ❑ Contractor Certification Requirements ❑ Other (Installer, Pumper, O&M Specialists) Description of Waiver/Appeal (include justification, additional material may be attached.): REDUCE VERTICAL SEPARATION FOR S to n d a 3ur` C2 S5 CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE Applicant Signature: Date: D 3Qn go9.4 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) o Appeal 'Waiver o None required o Class A K'Class B o Class C 2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/Standard revision): WAC246-272A-0230, TABLE VI 3. N e of A eal: DUCE VE TICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL GRAVITY OR PR SSUR OSS. 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ 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 6. I have received this waiver/appeal request. It is complete and mitigation required by the state and local p as been submitted. Staff Signature: Date: PART 4: Determina on t Hearing Official .-The hearing officia 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: / / 'L SL evised 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2of2 MASON COUNTY al. ';1 COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH CLASS B WAIVER WORKSHEET Building,Planning,EnvironmentalentalalEnvironmentalHeHealth.Community Health 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 APPUCANr NAME D r f Qi1 Ca s`L' �• WAIVER PERMIT NUMBER WA cr MAILING ADDRESS / L( \AI P IV.G�S(dt- A�[i Tr 30 0 G /� CRY S P O Kc-*L- STATE W ZIP /R a /Q I SITE ADDRESS 3 I L/ CI aL,,d, -- n` art JC. TAX PARCEL NUMBER a a A A Z-7 7 !O 0 V- Lf PROPOSED TYP: ❑ C:^,NVE NCIONAL Gnc,TTY <ONVENT1ONAL 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 0 ❑ Greater than 12" — j Harstine Gravelly Sandy Loam 0 ❑ Greater than 18" 0 (❑ Hoodsport Gravelly Sandy Loam ❑ ❑ -Determined by: Shelton Gravelly Sandy Loam RI/ ❑ Depth to hardpan ❑i ❑ Sinclair Gravelly Sandy LoamDepth to mottling I. Other ❑ ❑ Both 0 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 LI ❑ _ -Evidence of seasonal water table: / Ili:Sand Li Yes (Z • ? Sandy Loam ❑ No LI II ` Percent Gravel: -Curtain Drain required: 0 ❑ 0 ( -Less than or equal to 35% �fl Yes r'-2-Greater than 35% — ❑ Lr AI q No 3.SOIL DRAINAGE: 7. HORIZONTAL SETBACKS: „C, C re t^ I Soils must be moderately well drained to well drained. 1 0 Primary Drainfield must maintain 200'from down-gradi- N / ent marine shorelines,surface waters,and wells. z Well Drained..._ ❑ Moderately Well Drained ❑ Are increased horizontal setbacks met: i 4...., 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 SO foot horizontal attenuation zone is required Pressure is allowed on 3%to 30%. down-gradient of the primary drainfield. Less than 3% ❑/ Ill there 50 ft or greater between the down 3%to 15%_.._...._...._. _ _ 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 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 MAT BE SCANNED AND AVAILABLE FOR PUBUC VIEW ON THE MASON COUNTYWEBSITE. 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) 1. Local Health Department/District (2) ian tei a S 1<r ___^--- —— (see instructions) Address: /308 W v-s stdt. w� po � 9 9a off_ Telephone: ('3(,0) "131 - 7 a q D. Signature: Property I ntification: (3) &ex.( _ as a .3- - 9 0 6 6L1 --- Section II. (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A— 0230 24" OF V/S FOR PRESSURE 12" OF V/S FOR PRESSURE OSS . , Subsection: TABLE VI Justification(mitigation measures to be provided): 0 COMPLETED CLASS B WAIVER CHECKLIST ATTACHED, (OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN. ZONE (AFN: Section M. (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) cif411-5•,' Comments/Conditions: (10) Type of Waiver: (11) [ ] Class A ig..Class B [ ]Class C—Request DOH review before granting? Yes_ No Neighbor Notification: (12) Required? Yes No_ If needea are agreements, easements, etc.properly filed? Yes _ No Section W. (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 4.A.pproved /Granted—Subject all comments,conditions and requirement noted in ections II and HI. Local Health Officer (13) Date: �..� (� 2,44 DOH 337-021 Page 26 of 32 2207771 Mason County WA 02/21/2024 03:02:49 PM DECL eRecorded #195213 RecFee: $303.50 Pages: 1 KITSAP LAW GROUP Return to: Kitsap Law Group 3212 NW Byron Street, Suite 101 Silverdale, WA 98383 DECLARATION OF COVENANT FOR ON-SITE SEWAGE ATTENUATION ZONE I(We)the undersigned grantors hereby declare this covenant and place the same on record. I(We)the grantor(s)herein,am(are)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 2 22 23 Subdivision Division Lot Range Township Section and having the Tax Parcel Number of: 22 2 2 3_ -- Z-- 9 Q 0 6 4 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 ofthe 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 2( S(Clay of �� b r i ,20 24. nature ` ✓ Signature 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 _day of P., ,20...)'t ,1Y6eA " personally appeared before me, who is known to be signer of ie above instrument,and acknowledged that he( te)(they)signed it. GIVEN under my hand and official seal the day and year last above writ n. 1LN� Notary Public in the 'tate of Washington, residing at t A.Sd_St� _ KELLY FALKNER My commission expires : a a J Notary Public State of Washington Commission It 21012434 My Comm. Expires Mar 7, 2025