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WAI2024-00033 - WAI - 4/10/2024
r ' �� 415 N.6*STREET,SHELTON WA 98594 MASON COUNTY 1 SHELTON:360427-9670,eA 400 COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 aoaa.a �a rmimmmd emu.�...+br�aa ELMA:360482-5269,ext.400 FAX:360-427-7798 Application for Waiver or Appeal Amount Paid: I ;t Receipt Number: 1q WAI �LOIA Q� 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 IAA-1-1 sm ' Telephone Mailing Address ��90a � �r rn,N- eT C 4 City State WA Zip q V 371y Parcel No. � — —/-AD © Site Address AD NE Mak! el Subdivision Name and Lot PART 2: Nature of Waiver/Appeal 151' Class B Reduce Vertical Separation ❑ Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations ❑ Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements ❑ Holding Tank WAG 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Onsite Standards ❑ 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 CONVENTIONAL GRAVITY CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE /J Applicant Signature: Date: "/-x-toye Revis d W2112017 This form may be scanned and available for public view on the Mason County Web site. Page l of 2 r PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(If applicable) ❑ Appeal VWaiver ❑ None required ❑ Class A 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 A 3. Nature of Appeal: REDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL RAVI OR PRESSURE OSS. 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control heading Board ❑ Public Health Director ❑ Certified Contractor Review Board E3' Environmental Health Manage 5. Mitigating Factors: CLASS B WAIVER CHECKLIST(MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN) RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE(AFN 22 124Cn7 ) L.fT OAr l�4.—Zo A.✓Nr�o�- 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: l Date: y 23 Z PART 4: Determin?,o, f 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: L� Re d 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 mm w w, w vM CLASS B WAIVER WORKSHEET als N.aTH STVEe-r,BLoae.SHELTCNwweaeaa (State and Local waiver forms required) SHELTW 3Bpa11...Er,.. BEIF a aXr21 7.ECr am c.YBJB ...ont.-FA%'..1Pee uRL N"e (as SF4&Wf, wRrrFPmMlrrft.aS WAI M .eaesess 1Ao2. 1"dN Rim CT i�' s7.. ILIA ae o1g37�f me 16o NE Ma1,193 ary R� L1.a1� iN PoA3LNVMRER f reCPoYBBMMPEIDME �OlMB1fCNrlaYw''I ❑CONYBITN_ aIiRES511RE 1.SOIL SERIES: 5.VERTICAL SEPARATION: The wil cedes must be Aldenvpod Harstine,Hoodsport Up-slope vertical wpantionmust be greacer[hanta' Shelton,or S"mds,Gravelly Sandy Loam. mrgraveyaM greater Man 1Tfor preswrt. Alderwood Gravelly Sandy Loam_.___--------------❑ ❑ Greaterthan 13'..........._._...___..____...._.__..__.. 11 ❑ Harstine Gravelly Sandy Loam.........._.._.............. ❑ ❑ Greater than l8"-------_.._____.._......_.__._. CJ Hoodsport Gravelly Sandy Loam......................... ❑ ❑ -Determined by: J Shelton Gravelly Sandy Loa on.....__..._._.___.._.... ❑ Depth to hardpan..._........._.......................... LYI (1 Sinclair Gravelly Sandy Loam__......___.................. Depthmmottling...............__.____._.._.._.._ ❑ ❑ Other ..___...❑ Both................___._______._._.._._.._..__._.___... ❑ 2.SOILTYPE: 6.WATER TABLE LEVEL: Shctypes must be Medium Sand,inamy Sand,wSaMy If test holessiwwevidenceufaseasoralwatertabb Loam.Gnvel perc='.st be less than or equalm35%. above res[dRive layecacurtaiodninmayberegulred Medium Sand....._........______........................... ❑ ❑ 2 -Evidenm of seasonal watertable: ry LoamySand._...................._.._____._..__..._..._....❑ ❑ m rs Yes._.._....._.............._............_....._._._.._.._----.----._...._ ❑ ❑ SandyLoam_................__..._._..__.___............. No_.......__..._.._....._....._.____._.._._.._.._.___.._._._._.. o Percent Graveh -Curtain Drain required: O m - lessthan or equal to35%......................--- Rf ❑ o Yes_........._....._..............................._.................._._.__. ❑J a❑�, Greaterthan 35%._..._..._........._._.___.__.....❑ ❑ 3' No....__._................._..........._....._.._...___...._...._...__....tl qr 3 3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: c c Swls must bemMerstely well tlralrledrowell tlnlneQ O PflmaryDnlnfiddmustmaintaln2W'fmmdowmgradl- p pI ent marine shorelines,surtace waters,and wells. Well Drained.._..__.._..____...___........._._.._................ }wF Moderately Well Drained_....___._ . _.. _...._.....❑ ❑ -Are increased horizontal setbadts met: r Other _ ❑ ❑ Yes.............._...._........._...__.._.---------- ...._..__._... 2da 'E' 4.DRAINFIELD SLOPE: B.ATTENUATON ZONE slopes must be between 3%to 30%. Gravitym only al 1owed on slopes from 3%to 15%. AWfcxtl tondlattenuationzon NhatiulrM Pressure Is allowed on 3%m 3(m, 1 dimn-gredient of the primary drainfield. Less than 3%.............................................__._. ❑ El -Is there 50 ft or greater between the down 3%to 15%...._........._.._._.__.._........_-------.__....._.. + gradient side of primary drainfield and 16%to 30%..._........_....._...__._.._._....._.__.._____ ❑ property boundary: J ❑ Greater than 30%..............._......................._.._....._. ❑ ❑ Wt.—................................_.._...__.___.____....___..._.___FD No..._..............................._..................__...___..... ❑ ❑ The 5e)foot h amodal attenuation zone is reokAmi to be recorded on the deed ofthe property as unlosidable pdorrotlesign approval.The attenuation zone is not robe used for the mntruction 0 roads,deele,pemo AFN' Q56e7 parking areas,ve hlalarinfer or other similar such uses.The owner must agree toall these conditions vmmaRameRy� mis EaNMuaysEsurwmrxonww�emNwnxvEwwTxErwsavmunrvwuvrz. 'Me°'°�7°'7 7 Charring Waivers;firtan 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 Name: (1) Local Health Department/District (2) DeAAS ...................... nevru,Iioruri ............. Address: ................. . ........ Telephone: ............. - ------- Signature: Property Identific(gon: (3) Section 11. (completed by applicant) WAC Number: (4) WACRequirement: (5) Waiver Sought: (6) 246-272A 02310 ----1 — �1 WOFVISF�.R .RAVITYO.S Subsection: TABLE VI 36" OF VIS FOR GRAVITY Justification linnigamm wassues to be provided): (7) COMPLETED CLASS B WAIVER CHECKLIST ATTACHED, (OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN. ............. ZONE (AFN. Section 111. (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) ................. Commuents/Conditions: (10) ................ Type of Waiver: (11) [ I Class A C4Class B Class C—Request DOH review before gcanting9 Yes_ No Neighbor Notification: (12) Required? Yes No I_ f needed, we agreements,easements,etc.properly filed? Yes — No Section IV. (completed by health officer) This Request For Waiver From State Regulations has been reviewed according to the previsions 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/Gran ubject to all comments,conditions and requirements noted in Sections IF and UL Local Health Officer (13) Date: �e I DOH 337-021 Page 26 of 32 2212567 MASON CO WA 0612712024 11 20 angl�DEECL u II gggI�1�g�I I�II�'I^ II I'l lry�ll�„I�'�I All l'f303.541 PaSes , RCLm to: ❑ennis and Darlene Stickle 12902 122nd Ave Ct E Puyallup WA 28374 DECLARA TION OF COVENANT FOR ON-SITE SEWAGE A77ENUA TIONZONE 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. Now:Range,township,section numbers are the la 5 digits of the parcel number) OR 2W 23N 09 Subdivision Division Lot Range Township Section and having the Tax Parcel Number of._M(19-_-77- 00260 on which the granmr(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 gramor(a)is(are)required m maintain a 50-foot horizontal attenuation zone down gradient ofthe on-site sewage system m facilitate treatment of the sewage effluent. It is the purpose ofthese grants and covenants to prevent certain practices hereinafter enumerated in the use ofthe grantors)land which might encumber the land set aside for further sewage treatment and disposal. NOW,THEREFORE,the grantor(s)agrees)and covenan (s)that said grantor(s),his(her)(their)heirs,successors abe assigns will not construct or install any trench,channel,ditch,mad cut,utility chase,or other structure of excavation what would intercept or serve 95 a conduit for migrating ground wC�_` Dated on this 27 day of J✓y z: .20,,LV Signature Signature State of Washington ) Countyafmwon QteYC¢ 1,the undersigned,a Notary Public in and for the above named County and Stare,do hereby certify that on this �dayof .\.r 20_jn_,%k h i:}..\<ne rc1L1e personally appeared before me, who is known to be signer ofthe above iestrament,and acknowledged that he(she)qthey signed it. GIVEN under my hand and official seal the day and year last above written. Notary Public in and the State of Washington, residing at "Pt<rLx. Co Arse NOTARYPUBLIC Mycommissionexpires: oe.Aa r 10 2o'd-) STATE OF WASHINGTON RICHELLE WEDGEWORTH Lic, No.23035854 My Appointment Expires OCTOBER 10,2027