HomeMy WebLinkAboutWAI2023-00090 - WAI Health Waiver - 9/6/2023 415 N.6a STREET,SHELTON WA 995M
MASON COUNTY SHELTON:360427-9670,ert 400
COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
wua.pwwp.e,m,v,,,,snarr�u.u.n,,.onrawm ELMA:360492-5269,en.400
FM:360427-7798
Application for Waiver or Appeal tep1ll��MII7� 0
Amount Paid: I Receipt Number_ OD SEP 0 6 2023
WAI 2023 - OC-pC�`(O BY:---�----
Instructions:
1. Complete Parts 1 and 2. No determination can be made until these parts are fully completed.
2. Fees maybe 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 p� f`f V 6 r Ti! m e bx I. I Telephone Z {3 S y 1 " 07U a
Mailing Address l •d • N o x 3 7(s
City CA 4.Lk C.— State I IJ .p Zip 3 S nl
Parcel No. /O� L
Site Address E t o y er. r a i- �s Le.�Xn GN1 f f/
p Sy y
Subdivision Name and Lot 1 C L Z e* ISI.Li kt P 3�b�
PART 2: Nature of Waiver/Appeal
151' Class B Reduce Vertical Separation ❑ Food Sanitation Requirements'
O Q�
Building Permit Review Policies ❑ Group B Water System RegulatioltS �j®
❑ Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements a�
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines Aw...
Cl Mason County Onsite Standards ❑ Departmental Determin"ns APR O
❑ Contractor Certification Requirements ❑ Other d,0'vC0 y ZQ
(Installer,Pumper,O&M Specialists) ✓Nry fN�j Zy
Description of WaivenAppeal(includejustiflication,additional material may be attached.): ✓q NMFNTq�HFq(rF
REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY OR?RL-8
CLASS B WAIVER CHECKLIST
RECORDED DECLARATICIN OF ATTENUATION ZONE AFiV,. 2.1077.ig
Applicant Signature: Date:
itNq.d smr2017
This fern may be sunned and available for public view on the Mason County Web nibs
Pege 1 af2
PART 3: Public Health Evaluation (Staff Use Only)
t. Type of Determination Required: Type of Onsite Waiver(if applicable)
❑ Appeal i/WWalver ❑ 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,
�B rm 36 fo ZN
4. Hearing Official:
❑ Board of Health ❑ Health Officer
O Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board t' Environmental Health Manager
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE(AFN Z O yT
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the
state and local policy has been submitted.
Staff Signature: !Yl/✓ Date: 3/2Y/ZUZL�
PART 4: Determination 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:--------- Date:
R sect 8212017
This form may,bescenned and available for public view on the Hawn County Web site.
Page 2 of 2
MASON COUNTY COMMUNITY SERVICES MASON COUNTY PUBLIC HEALTH
... . v CLASS B WAIVER WORKSHEET
inca3revoe.. (Steteand lnrnlswiver f.required)
SXELiOM SaJ♦ZI%A.ES!CO.P£IfiVR Sal T3M61.ET.Im
EIYA a0aad]«,E%!tl0-HJ[M6aZl-)rya
Tu r - L LV(/ WAI Zozl -om yo
0Ia (Ia- .1.4 a ae !gzss- "
maoo � [nJeCCe) J- L,. (.6,
a k�r 77 01 R — 7 C.— 9 OG 3 / .a««eo era ,, 0-�L« ❑c� ua
I.SOIL SERIES: S.VERTICAL SEPARATION:
metal senesmusctenarawdrraenne noodWort, upsiape.anoiszvaanan mirs[t<greartr wore•
Shamrt«Smdar G.rsenyvMy Loam. twgaaaYard9maav Man u•r«pesure.
A clervrood Gravely sandy roam ❑ ❑ Grertcthantr ❑ ❑
Harstlne Gravelly sandy loan 9 Groatr Man llY— -- la EI
Hoodsp«t Gravelly scaly Loam 9 -Ddw tlnad by:
sheban GavdbsardY W«n ❑ ❑ Deptlimhrdpan U
Sinclair Gravdbsandy loam ❑ ❑ Deptlr fo mottling ❑
Other —❑ ❑ lied, ____.__. ❑ ❑
2.SOILTYPE: 6.WATERTABLE LEVEL
SaltypesmustoeMedlum Sand Loamsaid«SaMY ateamesstwre.m«ceaasea«w va4rGole
Loan Craiel pementmus[belmtlwn«equdm3s% aoweresnkWebyeca curtMndram matberegWred
Medium Sand____..___ ❑ _ -EvManuataaasawY vaMabla:
Loamy Sand ❑ ❑ B Yes— --- ❑ t11
a
S«dYlnam..____ BI 9 g w B J" s
Prcent Grata: -caetwla11,610
-1essthanorNua1m35% yl oat Yes ❑
-Grmhr Man 35% ❑ ❑ Hn L�!'
3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS:
sat manse moaerateyxeildrammav ridnnea $ L^�a�rDa�iemusfmamtan zoarmm eow.eyaai- R
s 1 rrmaneea�«dina:,nra«.a�sa.dn S
Well Drained._. ❑ ❑
ModratelyWell Drained C4 -1lnlavawdbar4aatalfatMel«aLae:
Other — ❑ ❑
4.DRAINFIELD SLOPE:
8.ATTENUATION ZONE
SlopesmmtM tavarm:%to3m6
v aatytoay amxeaanswpeoom3%m ss% nwromivnonwaff«Luauanzorenreymr.a
Pnswret albvx,I 3%m3W6. domrgradknfawprinurytralaW.
Less than 3%_ ❑ �Istlwal Sgieargraaar balr3aentboda%n
a%tots% SldlaypdWydraleMldarrd
Greater than 30%— ❑ ❑ Vas
Ho ❑
3lrewman«ImmaiattmuadmmnaKraaulmamoererdaea onu,edEe6aMe paprfya patie% la RJ:
M 22U4z 9�pnorm design approval.lheathnuatlanzore bnoem beuad for Mecvnnucnonama drAy panoa p
padMgaresa MaalatrAR4«otlereadW wMusa Movnarmuslaprtemi remidMorw �weK
TMraMaurrtzuxxmuoaw�aeL[rwwaKvewoxnaauWlmunrNffinR Wka»mil
Gmn=g waives from State On-Sire Sewage Sywcm Regulations Chaper246-YM WAC
Effective Date: July 1,2007 Revised April 2017
On-Site Sewage Systems(Chapter 246-272A WAC)
Request for Waiver from State Regulations
Section (t'umpleted by applicami
Name: (I) Local Health Department/District (2)
vu r u r-Pi 5,,f ee in ry t on
Address: P 0 , (S a 3 7(e
01 g4r, vl > qxSSt/
Telephone: ( ) p
S � g702)
Signature:
Property I a 'on: (3) O
ou<- C cc 5 It, wa q S
Section K (ranTl d byaPpitrma)
WAC Number. (0) WAC Regimcmmm (5) war—sought: (6)
246-272A— 02W '2 )
Subsection: TABLE VI 36-OF V/S FOR GRAVITY 1 18-OF V/S FOR GRAVITY OSS
Jusfifieetion(mitigation menemve to be provide: (7) COMPLETED CLASS B WAIVER CHECKLIST ATTACHED,
(OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN.
ZONE(AFN: Zzo?zfg
Section In. (campleted by health ogee')
Review Criteria (8) Mitigation Measures(in addition to thare prnpasesil: (V)
Commandos/Conditions: (10) We- C trI t
Type of Waiver. (11) i ]Claw A 1A Class B ]Class C—Request DOH review Writes,gaming? Yes No�f
Neighbor Notification: (12) Required? Yes_ No X Ijree&d,are agtnenraas,earenrartr,etc.properly/fled% Yea No
Section tv. I (rompleted 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 measwes proposed aM/orrequired,have been evaluated for their ability
to provide public health pitu ctimi at least equal to thm provided by this chapter WAC.
( ]Denied ftAppraved/Granted--Subject to cormrencs,conditions and requfrernents 11 and HI.
Local Health Officer (13) —_.. Date: Z L�
DOH 337-021 Page 26 of 32
2209298MASON C WA
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,UW TURNBBLL #196359 Rec Fee $306.5gp0 P as. 2
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Return To RFC ry4.?,g
I1. 170k 3 6
ola) )aT 41a 1935Q
s
Grantor(s): (1)
Grantee(s): (1) PUBLIC �7
Legal Description (1) 19 2 0 A/ D W
(Abbreviated loan:i.e. lot block,plat orsection, township, range)
Assessor's Tax Parcel: (1) 2 2 0 o 3 L
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 3 day of l�l _, 20_Z�.
Page 1 of 2
Signature of Graantoo/r(s):
(t)a (2)
State of Washington )
County of Mason )
I,the undersigned, a otary Publi .n and f the above..nn�arrlmLed County and State, do hereby
S that on"t�'�,y' day of • 20L�1
. f, BOY YA/t�IY personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that h he) (they) signed it.
GIVEN under my hand and official seal the day a d ye I above written.
NOTARY PUBLIC
STATE OF WASHINGTON Notary bli a d or t e tale of W shington,
JACOUALINE A. CASE residing at
Uc. No.22016377
My Appointment Expires My commission expires:
APRIL 08, 2028
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