HomeMy WebLinkAboutWAI2024-00054 - WAI Health Waiver - 5/2/2024 415 N.EP STREET,SHELTON WA 98584
MASON COUNTY SHELTON:360427-9670,eat 400
COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400
ELMA:360-482-5269,ex[400
amidh%Piam,pn%a wmmmi�m.commnib HNM FAX:360-427-7798
A hplication for Waiver or Appeal
: U 25f,
Amount Paid: OLa 5 Receipt Number 1�
wAi LbGIA - OM 54
Instructions:
1. Complete Parts 1 and 2. No determination can be made until these parts are fully comde[ed.
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�mot_] c__� � �,
Name of Applicant —�� "" ') Telephone S 0-7 —ZH — 5T405
Mailing Address O 30� (Q 0
city S (n e-1 state VIA Zip Q 5'S9-q
Parcel No. L' Z D Z .5 _ 7 .S _ O d 2 3 D
Site Address 71' 0 W w y l t vj o-o r) 'Drive u/A 1r-rFq
Subdivision Name and Lot
PART 2: Nature of Waiver(Appeal
ISI` Class B Reduce Vertical Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Locadon,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements ❑ Other
(Installer, Pumper, 0&M Specialists)
Description of Waiver/Appeal (include justification, additional material may be attached.):
REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY OR PRESSURE OSS
CLASS B WAIVER CHECKLIST
RECORDED DECLARATION OF ATTENUATION ZONE
Applicant Signature: `— �— Date: o ro now
Revised 01n017
This form may be scanned and available for public view on the Mason County Web site.
Page 1 oF2
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 VClass 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
PRESSURE OSS.
4. Hearing Official:
D Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board El' Environmental Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE(AFN
6. 1 have received this walver/appeal request. It is complete and mitigation required by the
state and local policy has been submitted.
Staff Signature: Date:
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: 7 j
Rc,l iWV2on
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
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)
Re nest for Waiver from State Regulations
Section L (completed by applicant)
Name: (1) Local Health Department I District (2)
e—t s� moil�r_`�✓� see Yudaenoru
Address: (a�,`4 () p...�
Sl a I n VAAr
Telephone: ..-
Sigmturc: Ta 11
property Identification:(J)
-7k6 Ld U! Rwoo W ke_( w, W 4tiT
0Vx0_4 : F 47-0 Z- -7 S+ro z.3 a Z 4FF _S S o
Section fi, 1 (completed by applicant)
WACNumber: (4) WAC Require mrnt (3) Waiver Sought: (6)
246-272A— 0230 24"OF V/S FOR PRESSURE (OR) 12" OF V/S FOR PRESSURE OSS OR
Subsection: TABLE VI 36"OF V/S FOR GRAVITY 18" OF V/S FOR GRAVITY OSS
Justification(mitigation measures to beprovided): (7) COMPLETED CLASS 8 WAIVER CHECKLIST ATTACHED,
(OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN.
ZONE (AFN:
Section [Q, I (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Condition: (I/)
Type of Waiver: (11) [ ]Class A [rychus B [ ]Class C—Request DOH revew before granting? Yes_ No_
Neighbor Notification: (12) Required? Yes_ No_ Ifneeded,are agreements, easements,etc.properly filed? Yes _ No
$e on Iv (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 noted in Sections 11 and HI.
Local Health ODicer (13) Date: 7 j
DOH 337-021
0MASON COUNTY MASON COUNTY PUBLIC HEALTH
COMMUNITY SERVICES
raNaoXraXNa.E.IA.m.olXaa,o,m�..NWN.am CLASS B WAIVER WORKSHEET
415 N.am MEET eIOG e.SneL7ON vw assay (State and Local wah er farms required)
SWLTON'.381N27-98711.EM.aW-eELFa a 7514V.EKE 40D
ELMA....W.aW-,F IA`(:,]90�117756
APPWAW S, C,� " PmanNotanNUNIEP WAI
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on.. 78 (ArYvuw"a) D/ t9—
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❑Co1nENWNALphooaE
1.SOIL SERIES: 5.VERTICAL SEPARATION:
The mil series mart be Aldeswood,Harsdnq Hoodsport Upslope vertical seWra[ion must be greater than 18'
Shelton,or5l id'Gravelly Santlytram. fagvviryantl g�S ran 12'for Iaressure.
Alderwood Gravelly Sandy foam... ..............__❑ ❑ Greater than 12'_.._.. ._.._.� ❑
Hantine Gravelly Sandy Loom................................ ❑ ❑ Greater than 18'__..
Haodsport Gravelly Sandy Loam_. ❑( ❑ -Determined by:
Situation Gravelly Sandy Learn 1z Depth tohardpan_,_..._ ❑ ❑
Sinclair Gravelly Sandy Loam ❑ ❑ Depth to molding ❑! I13
Other " ---❑ ❑ Both............................_.._........................................_.. T
2.SOIL TYPE: 6.WATERTABLE LEVEL: ��
Sall types must beMMium SarM,Loamy Sang or Sandy If testhok3.M1'h evltler .fazeasona -so"table t
Loam.Gravel percm[mun beless than or equalro 35% above rertrictive layeta curtain drain may be required
Medium Sand!____.__._._._._._—� ❑ _ -Evldt osaiwiseasonalwatertable:
Loamy Sand.____.____ ❑ $ Yes__.___._..__._._______.._.._....,..._Pn Q if
SandyLoam__.__ _�___❑ ` No..__..___..................................
Percent Gravel: -Curtain Drain required:
.Less than or equal to 35%................._...._...._.. ❑ Yes_..._._ ...__..._,._.__._._____._.___..❑ ❑
-Greater than 35% ....... .......___..._._...._..----- Fi( Ip
3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS:
h 6
as Pdmary Drainfield must malntaln 200'irom downgradF n
SdIr TUrtbe moderahlyvMld2ined to well tlralretl. S p
ent marine sM1IXe8ne5,surface wateq and wills. p
t
WellDrained..........._.............._...._.........................._. 6l
Moderately Well Drained__.__.__..._❑ -Are increased horleerMal satbacha met: `
Other ..___.__ ❑ ❑ Yes_.._._.__.---------
._..—�.__.y61
No__..__..._..._._......_.__._._........____.❑
4.DRAINFIELD SLOPE:
B.ATTENUATION ZONE
Stapes must be between 3%to 3096.
Gravity is only ali on slopes from 3%to 15%. A SO foot horizontal attenuation zone is requlred
Pressure Is allowed on 3%to 30% cim"adlento/the primary drainfietd.
Less than 3%.................._...................._...................._.a❑� ❑ -Is
the.50 ftart greater bet3vxn the down
3%to 15%...—�. ,ql [Y� gradient side of primary draiMuld and
1896to30%......................_...........__............ _. . ❑ tL] property boundary: 1{
Greaterthan 30%..............._..._........__......._............. ❑ ❑ Yes......_.._...__..........._......._............_.__._.__.61
No_.,._._...____. ___...,... ❑
The 50 foot horhomal attenuation acne is required to be recorded an the deed ofthe property as unbuildable q
prior to design approval.The attenuation mon h not to be used for the teneM uon M mads,decks.patios AFN' t-7- Jll�i
parking area,veM1lcular[refic or other similar such uses.Theowner must agree to all these Wnouomi vAnalwamiy
IRIS FmMNJn OEYN&Ea ANa INNWIE WPNPLIC WPMOXnIEN15oNCWNiY WFaSnE. uplerta VLlol)
2233&q rows co MA
Rnum Ta �.
L-nrh, ROM l �
RJ fs) L4A
Grentorlalafl ^ a U�W
Ominous):(t)PUBLIC
Legal Descnpbon 111
illlll'
(AbbreNnedform:La.KK,dock,pinay ,mxnehip,nnp)
sesessoe.t'sv Popk(t)4-
DECLARATION OF COVENS O tl-SITE SEWAGE ATTENUATION ZONE
I(We)the gnrmor(s)We*.Mnlamit�IMbamera m No stmpla of(an udshost er)Me
v
deecnbetl rest ennartunatl inv'gwn Count,SIna of Washington;hereby tlacleratM1ia
.d.nam L PV.plis� an ,
To wt[he EescrlQetl n on attach Me grimwga)awns and operates he omsile sewage
dispoaal station w)ik11 be.t/pn gore ed a Cities 5&ate WeNer to reduce the Minimum
Vertical$'epadtiarr\irlpuimments and gramn(el le(are)reoured to maintain a hbfoot
harizoM1[fleaissfuadon zone down gradient of the on-site sewage system to Incilitate
treatmynt o(tha as w,ge eNluem.
—,A
R/A t1r plpbee of then Hrente and cwananu to prewm curtain Pncti<ea M1ereinahar
' t
a(,1lptaratW,ln the use of the grentoga)and which might encumber the land en aside for
sge treatment and dlapoeel- p JUeupn n
��w I ll"
\-i1BW,tHEREFORE,the grantoRs)sitter )and cwenant(a` n �1jWitter)
C �\` Mirl heirs,auccmaora and evaigna vnll not construct oETnrliVVen _Ldite h.
NpTAnv
�reW cut,wiliry chase,or the,atmewre meacewtim wjfotig9.Id pleaerpe as
conduit for mi®ating ground water.
Doted on this l2 day
SlgnstuneotGon (g).L`
Sate of WashinponlCowm/of Masonll,the untlenlgned,eN ryPuplic na l/rW tort/ w eabenemed
County and Stab,do hereby certify that on this_a_dey of 29;L
�V--tfl lIntHl Ak,`X�parvon*dt "red before me, a is lmewn to be shiner of the show
instrument,and acke dged�he phe gnad it.GIVEN under my hand and affected anal the day
antlyeerUnabew eelmin. Notary Publiclnandbrthe SInaof
Wunmgton,realtling et � � MYCOmmiaaian¢apirea: [i/ice/dS _