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Home My WebLink AboutWAI2024-00066 - WAI Health Waiver - 7/12/2024 � � 415 N.a STREET,SHELTON WA 98584 MASON COUNTY SHELTON:360-427-9670,ext 400 COMMUNITY SERVICES BELFAIR:360-275-4467,ext.400 \ emminawnm�aawrvenmenai xemn,(cmmlm�ryxeann ELMA:360-482-5269,ext.400 FAX:360-427-7798 Application for Waiver or Appeal Amount Paid: Receipt Number. WAI aoaLA - 0QO 6l7 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�nP.joy') Marl,arl, 003-- Telephone Mailingf� 7'r Add,Iress ri Cffit'K 4"rt . L� City L:G& I? State_� Zip —moA Parcel No. I 0 0, O O a, Q She Address C 14ar4ins- sk. k - ' Subdivision Name and Lot PART 2: Nature of Waiver/Appeal 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 WAC 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Onsite Standards ❑ Departmental Determinations ❑ Contractor Certification Requirements ❑ Other (Installer, Pumper,08M Specialists) Description of Waiver/Appeal(include justification,additional material may be attached.): REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITYi CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE : Z Z I3SOD Applicant Signature: Date: 7• rz.?,NZzio Revised&/212017 This form may be scanned and available for public view on the Mason County Web site. Pe 1of2 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 V'Class B ❑ Class C 2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/Standard revision): WAC246272A-0230,TABLE VI 3. Nature of Appeal: REDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL GRAVITY CMr #Y2E8JtiRE055: 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ 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 ?Z 1SS06 I 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: 40 Date:- may PART 4: Determination of the Hearing Official P„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: amua entnov This form may be scanned and available for public view on the Mason County Web site. Pege 2 af2 0MASON COUNTY MASON COUNTY PUBLIC HEALTH COMMUNITY SERVICES Wk5na.Nmmr.oam to HwW COMIMIn Hnm CLASS B WAIVER WORKSHEET 415 N.sm sraEEr,BLoo e.sxeL.oN sun MS" (State and Local waiver forms required) sH=N:360�Z]A6]0,E ..40 -BEIFNR sa0.275A 67.W,90J EW 's� i ao,8a 62269..EM.4m -r W42]-]]BB P4NGN r N r//I ake /Alrw Y /2&riA Oos-r wMRAPFAwmuaea, WAI 2/ Z r —IzoIM AwuncrooBEss 'I�i/3 \ VV cm P, u+-rop sratE ��. aB 7X609 snEaoo6Ess UAl E _3eIo, k Qd S _ cm ��te.l�rsin M aUrcoxaMBEO I)LO10, —15- DO()10 _ rmwsrnwumnuo]rvE [(carmwrnrwL ovxm ❑ GawwaoO a R165UK 1.SOIL SERIES: 5.VERTICAL SEPARATION: The soilseriesmurt he Alderwood,Harsline,Hoodsport, Up-slope vertical separation must be greater than lr 5hekan,or Sinclair Gravelly Sandy Loam, for gravity and greater than 12'for pressure Alderwocd Gravelly Sandy Loam_._..._.._..___...❑ ❑ Greater than lT........_...._.__._.._._........_.___ ❑ ❑ Harstine Gravelly Sandy Loam.._.............._... ❑ ❑ Greater than Hoodsport Gravelly Sandy Loam_._..____.__... ❑ ❑ -Determined by: Shekon Grave . Sandy Loam_.__._..�___._...1i' OR" Depth to hardpan_._...__._...._________._.... ❑ ❑ Sinclair Gravel Sandy Loam_....------___.❑ ❑ Depth to mottling_.__._...__.._.__._..__.__._. ❑ (H Other ___..❑ ❑ Both.._......_...._._......................................._ ❑ ❑ 2.SOILTYPE: 6.WATER TABLE LEVEL: Soilrypez must be Madlum Sand Loamy Sand,or Sandy k[est holes show evidence of a seasonal water table Laam.Gravel percent munbe less than or equal o35%. abowrertrktive layer,a amain drain may be required Medium Sand_..._....._._._.__.__.._..__._.._......... ❑ ❑ _ -Evidence of seasonal water table: LoamySand_..__....................___.._.__.... L7 0 Yes.........__.........................................—. ❑ ❑ Sandy Loam____._.__...___.__._..—__....❑ ❑ percent Gravel: -Curtain Drain required: o -Less than or equal to 35%_._................._._._. � �o ❑ ❑ M1 n - Greaterthan 35%......___.__........_.._....._._.....❑ El3. No_._.__.___._._.___.___._____.__�._ LC3T' 3 3.SOIL DRAINAGE: c 7.HORIZONTAL SETBACKS: c Sdhmustbemoderatelywelldminedwo ildalned. p. Primary Drainnald mug maintain 2oafrom down- aal- p ant marine shorelines,surface waters,aM waltzgr t Well ermined Moderately Well brained._.._..__._ -Areinaeased horizontal setbacks met: Other ❑ Yes____._...__ 4.DRAINFIELD SLOPE: B-ATTENUATION ZONE Slopes must be between 3%to 30%. Gravity Is only allowed on slopes from 3%to 15%. A 50 foot hodwrl attenuation orris required Pressure is allowed on 3%to 30 downgma dent of the pdmarydrainfield. Less than 3%._._..._._._.._._._._.----------—.--- L� f -is there 50 ft or greater between the down 3%to 15%._.._....._..__._._._.._.___._-.—.-.-.- ❑ ❑- gradient side of primary dminfield and 16%to 3096 ❑ ❑ property boundary: Greater than 30%------------ ❑ Q Yes........... ................._ _............ ___ '2 El The 50 foot homontal attenuation am 6 required to be recorded on the deed ofthe property as unbuikable aZ13J 0(/ pniorto design approval.The attenuation one is notto be used or the contruction of roads,decks,pados, AFN: parking areas vehlculartraft orother similar such uses.The owner murt agree W all these conditions. wonwum�m�s: t 51owal BEz EDANonvalue.EraxvuaucnexoNWE Mas C)JrnwaeM uVd.rcesnaon 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) tA Local Health Department/Drsttict (2) lldftlJ Irlaf�s. '� (see instrucnans) Address: Telephone: Signal=: �1 /? C✓ct' Property lden cation: (3) a2rlt __ Section H. (completed byapplicant) 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, LUTLINING ADDITIONAL REQUIREMENTS_ MET). RECORDED DECLA_RA_T_ION OF COVENANT FOR ATTN. NE (AFN: Z i.,Section HL d- (completed by health officer) Review Criteria: (8) Mitigation Measures addition to those proposed): (9) Comments/Conditions: (10) (t(' - Type of Waiver: (11) [ ]Class A Class B [ ]Class C—Request DOH review before seeming? Yes_ No Y Neighbor Notification: (12) Requimd? Yes_ No4 lfneeded are agreements,easements,etc,properly filed? Yes _ No_ Section W. I (completed by healthofwer) 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 then ability to provide public health protection at least equal to that provided by this chapter WAC. [ ] Denied Approved/Grant W—Sbj5pd all comments,conditions and requirements 1noted in Sections II and TH. Local Health Officer (13) Date: d/ l f 70 z_y DOH 337-021 Page 26 of 32 2213500 MASON CO WA A09T, MAR n11#199677 Mec Fea- $303 50 Pa9e 1 IIIIIII II III IIII IIIIIII III(IIIIIII IIIII IIIII(IIIII IIIII IIIII IIII IIII JUL 1.9 'tu14 Return to: DECLARATION OF COVENANT FOR ON-SITE SEWA GE A TTFNUA TION ZONE I(We)the undersigned granmrs hereby declare this covenant and place the same on record. I(We)the gmntor(s)herein,am(arc)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 1 gi Subdivision Division Lot //�s��ss Range Township Section and having the I.Parcel Number of a,Q.1y-3 J[fLr— Yaa on which the grantor(s)owns and operates an on-site sewage disposal system which has been granted a Class B Waiver in induce Minimum Vertical Separation requirements and grantor(s)is(are)required to maintain a 50-foot horizontal atte nation zone down gradient of the on-site sewage system to fecilitate treatment of the sewage effluent It is the purpose of these grants and covemnts to prevent certain practices hereinafter enumerated in the use of the granto(s)land which might encumber the land set aside for further sewage treatment and disposal. NOW,THEREFORE,the grantors)agree(s)and covenants)that said granlor(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 save as �a conduit fro migrating ground water. Dated on this 9 R f � / 20_ Ai• Z f S,gwmru Signature State of Washington. ) CoumyofMason ) �I st,h�.e, undemi d,"Notary Public in and for the above named County and State,de hereby certify that on this der of 2 , AUeja t%S'r personal) appeared before me, l.�- y y who is known to be si 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 vF1nor. � �ryf�,,�� qunnnt/ 4kAfh AA WA C / Notary Pu M ig in and for th State of shin n, residing at // MtAkVA �tiQ:•A��5-2O 'o/.G'L My wmmission expires Wu aO7ARY __ '�.9T•..Numwt.+�av