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Home My WebLink AboutWAI Health Waiver MASON COUNTY COMMUNITY SERVICES Building,Planning Envirm mental Health Community Health 415 N 6"Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 t• Elma: (360)482-5269 ext 400 FAX (360)427-7787 Application for WaiverlAppeal Amount Paid: 4 Receipt Number. 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 Identification Name of Applicant Franklin Clark Telephone 360.830.4765 Mailing Address of Applicant PO.BOx 1954 City Silverdale State WA Zip 98383 12-digit Tax Parcel No. 2 2 2 2 3 -- 5 1 -- 0 5 0 2 0 Site Address 1291 E.Trails End Dr.,Belfair,WA 98528 Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Contractor Certification Requirements ❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists) ■ 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 ❑ Other Description of Waiver/Appeal (include justification, additional material may be attached.): 1 ordinary 3 Waiver Jpstl{ICdtlOnandMibaation WeareusimnganOSC R402septicsystemwhichmeetsIreatmentlevelA Applicant Signature- ? ^ 'k( 1,. CJ Date: 21 May 2024 1:Vi11 Forms\Waiver-Appeal Mason County Lmal Revised 1/20/2019 Page I of 2 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) -: Appeal rlWaiver L None required `lass A u Class B YClass c 2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/ Standard revision) G y-7ZA Q7-4 (D 3. Nature of Appeal. R� Jlucs hw{�rht+Rl �fbia(i fmy✓) oEtarnFTee� 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board X Environmental Health Manager 5. Mitigating Factors. J:V� A J"t phi 1u C1u/ 17�4 'Gv{ J L4 101 ) 5. I have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. Staff Signature: N� Date: PART 4: Determination of the Hearing Official PL The hearing official has determined that approval of this request will not adversely affect public health and is hereby granted.Tljs decision is based gn the following fi:jngs and OIf �t wnditinonse : l4C< I qG N u l., e F s D � ! ❑ 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: Hearing Official Signature: Date: 1:V111 I o ms\Waiver-Appeal Mason County Local Revised 1/20/2017 Page 2 of 2 Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC Effective Dale: July 1,2007 Revised April 2017 On-Site Sewage Systems (Chapter 246-272A WAC) Re uest for Waiver from State Regulations Section t. (completed by appkcanQ Name Franklin Clark-WA Onsite Wastewater Treatment Local Health Department/District System Designer (see insauctions) Address: P.O. Box 1954 Silverdale,WA 98383-1954 Telephone: (360) 620-8857 Signature: c (� Property Identification: 91 E.Trails End Dc, Belfair,WA 98528 Parcel ID:222235105O20 Tax Description:TRAILS END DIV#2, Lot 20,Block 5 Section II. 1 (completed by applicant) WAC Number: 246-272A WAC Requirement:1. Enhancedtreatmentperformance Waiver Sought Setba6fmmsurfurewaterto50'>. 2.Performanceassurance of treatment system Subsection: -0210 3.Hydrogeologic susceptibility Justification(mitigotionmeasuresto beprovided):, OnsdeWastewaterheatment System Designed isa Low Ridgeltechndogles OSCAR-X02 wastewater treatment system which meets Treatment level`A'. 2 A Notice of Operation and Maintenance of On Ste Sewage System will be recorded on the property. 3.Soil Logs nthe identified Primaryand Reserve Drain Field Areas show no signs of Hydroge scigic susceptibility,recorded soil rags indicate Fine Sand Loamsto a depth of 24'with no idication of rust staining. Section 111. (completed by health officer) Review Criteria: Mitigation Measures(in addition to(hose proposed): Comments/Conditions: L L Type of Waiver: 'W ass A [ I Class B Class C Request DOH review before granting? Yes No Neighbor Notification: Required? Yes No lfneeded, are agreements, easements, etc.properly filed? Yes No Section IV. (completed by healihofficer) 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 provid d by this chapter WAC. ��d [ I Denied Y Approved/Gra ted ect to all comments,conditions and requirements noted in Sections II and 111, Local Health Officer Date: Z- DOH 337-021 Page 26 of 32 2215399 MASON CO WA PNORErRO 101]61I21 RaoTFae: IIV 304.fi0 Paaea: 2 IIII�IIIIIII�IINI®IIImIIIIIIVIII�III�IIIIIIIIVIhNIII __ _ Return To Andre Rowe 7002 149th St E Puyallup,WA 98375 _ Grantor(,): (1) ANDRE ROWE ET UX (2) Grantee(s): (1) PUBLIC Legal Description(1) 1291 E.Trails End Dr.,Belfair,WA 98528 TRAILS END DIV 112,Lot 20,Block 5 (Abbreviated form:i-e. lot, block,plat orsection, township, range) Assessors Tax Parcel: (t)22223 - 5.!_-_05020 NOTICE OF OPERATION AND MAINTENANCE OF ON-SITE SEWAGE SYSTEM (We)the undersigned grantor, hereby place this notice on record that the described real estate situated in Mason County, State of Washington; to wit the described real estate is served by an on-site sewage system that was approved and permitted on the condition that it would receive on-going operation and maintenance to assure it would continue to function in a manner that provides adequate treatment and disposal of sewage. Operation and maintenance of the on-site sewage treatment and disposal system must be done In accordance with the Mason County On-Site Standards, the Mason County Board of Health On-Site Sewage Regulations and Washington State Administrative Code: 246.272A On-Site Sewage Systems. - - — - -- These covenants shall run with the land and shall be binding to all parties having or acquiring any right, title, or interest In the land described herein or any part thereof, and shall Inure to the benefits of each owner thereof. Dated on this I day of 2023_. Signature of Grantor(s�): (1) (2) Page 1 of.2 'r, State of Washington ) County of Mason-Qfe1e� ) 1,the undersigned, alotary Public in and for the above named County and State,do hereby certify that on this I day of rZU , 202N , Anlre Qo,ra personally appeared before me,who is known to be signer of the above instrument,and acknowledged that he(she) (they)signed ft. GIVEN under my hand and official seal the day and year last above written. Notuy llhrb4c Notary-Public in and for the State of Washington- — - Slobo(Wrebtnetan residing at awriL GJ� �gyyB01,Ap1D My commission expires: A.nuS} 6 AUGUST 10.2M Page 2 of 2