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Home My WebLink AboutWAI2024-00079 - WAI Health Waiver - 8/13/2024 MASON COUNTY 415 N.6'STREET,SHELTON WA 98584 SHELTON:360-427-9670,ext 400 COMMUNITY SERVICES BELFAIR:360-275-4467,en.400 eane`y.m.mmy rnHrwmenuixeaiu.ranminWxwlA ELMA:360482-5269,e#.400 FAX:360427-7798 Applicatio for Waiver or Appeal p Amount PaidA� Receipt Number: lJ2L"I Ll=� l V WAI ?.o N- O O 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 14V14-ce^Ik- Telephone -(ao--1S3- VL-"' Mailing Address P,O. CSo,( llo-+- city cl�LY State wA Zip g6 SO-f Parcel No. P- 9- i .� 3 — 7, k — S O O 0 -L- SiteAddress C. '(�CJL-rGYL-r+SC. M6 Subdivision Name and Lot L—�S 'ZoL—02 c—o T •L PART 2: Nature of Waiver/Appeal d 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 WACP46-27 ❑ Enforcement Timelines ❑ �p2 �g 2 M r2D Mason County Onsi[e Standards ❑ Departmental Determinations LLSS 117 LS Ll IS ❑ Contractor Certification Requirements ❑ Other (Installer,Pumper, 08M Specialists) AUG 1 3 2024 Description of WaiverlAppeal(include justification,addifional material may be attached.): By REDUCE VERTICAL SEPARATION FOR CONVENTIONAL GRAVITY OR PRESSURE CLASS B WAIVER CHECKLIST RECORDED DECLARATION OF ATTENUATION ZONE Applicant Signature: 4M Date: >!'i 'L Revised grzv2on This form may be scanned and available for public view on the Mason County Web site. Page I oF2 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑Appeal &(Waiver ❑ None required ❑Class A &(Class B ❑ Class C 2. Identification of Specific Code/Standard/Determination (include date of determination or latest Cede/Standard revision): WAC246-272A-0230,TABLE VI 3. Nature of Appeal: REDUCE VERTICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL GRAVITY OR PRESSURE OSS. 4. Hearing Official: ❑ Board of Health ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board a 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 waiver/appeal request. It is complete and mitigation required by the stale and local policy has been submitted. l (� Staff Signature: Date: PART 4: Determination of the Hearing Official lj -dhe 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: O 'lf V1 ay- ud 8/21/2017 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 AUG 1 3 2024 MASON COUNTY MASON COUNTY PU ILNEALTH COMMUNITY SERVICES CLASS B WAIVER WORKSHE coN mX srm{r,onaGB.aIELICMw"waax (State and Local waiver forms required) sX ,,e,.aWJzz W10.W as,-.."In awars"al,eM aW E.....-FM'YWaI-1199 w.A MM M1K� 7owt/560 w,wenerea„,. WAIU7,4—GYJo7q uvlaw xzxms-`�f --/J� r 1"� as 9 ya smmwass G1' on conudanwnee—st 1-5-5- Z - DO mCegxmeaenr9pMa ❑mlrwlludlarx+my uLaL 1.SOIL SERIES: S.VERTICAL SEPARATION: Thesoll swks must be Alderwood,Hantine,Hacdspon, Up none vertkal separatlon must begreakr Man lB' SM1Nron,or Slndalr Gravtlly Santly Lwm. ,,,....../// forgraWryantl greater ManlTkrpressurt. r,.� Alderwood Gravelly Sandy Loam...__......_._....- yq Greaterthan lP.._..............._....................................__ l}I� HarsOne Gravelly Sandy Loam....._..._...._........ ❑ Greaterthan lA"...........................__................_ ❑ ❑ Hoodsport Gravelly Sandy Loam..._.................. ❑ ❑ -Determined by: Shelton Gravelly Sandy Loam....._......_...............❑ ❑ Depth to _. ❑ ❑ Y Y -- P g.................._.._.............._ ❑ ❑ Sinclair Gravelly Santl Loam...._......._........_ ...❑ ❑ Depth Met ._....._❑ ❑ Both........____..._...__..__..._..._...._...._...__ ❑ C, 2.SOIL TYPE: 6.WATER TABLE LEVEL: Solitypesmustlrs Medium Sand,Loamy SZM.pr Sandy If test M1olez xXoweWdena INa zeazonalwa[er table ,�,✓ u m.Gneelpace —stbe lessthance equal ro 35% above rexalctive layepa curtain dlaln may be regWred �•((ytry�/ Medium Sand.__..__...__..___........_..._.._.❑ ❑ _ -Evidence of seasonal watertable: ,,,,(( � s!� LoamySand.........._.....-_._....__..._...._...._._.....k ❑ c Yes......................................................_......_....._.._..d ❑ ,a Sandy Loam.........._....._......__..._..._..._......... 7 No Y^ . . . . . . . .........................................._...._......_._.....__....❑ Percent Gravel: b -Curtaln Drain iequind: p m -Less than or equal to 35%._........._........... ❑ 14 � Yes..............................................._.._.............. o -Greater than 35%................_..............._...._.❑ ❑ No._......._............................_....._..._..............Elk 54 4 3 3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: u c SCMx must be moderately well drafired to well MalrKtl. O PrimarymarimsM must M!nem dxtain mtwtr adnwmgeatll- $ mtmarire slwralines wrtxe watwxahW suck. � WeIIDmlord..._._._............._................. .................. ❑e.,,gg ❑ Moderately Well Drained....._....................._...V b. -Are increased horizontal setbacks met: Other ........... ❑ ❑ Yes................................................................................. No__........................................................................... 4.DRAINFIELD SLOPE: 8.ATTENUATION ZONE Slopes must be between 3%k 30%. Gravity Is only allowed on slopes from 3%to 15%. A50foothodeontuanenumone, requlretl Pressure Is allowed on 3%k 3014. down9latlknt of the primary dralnfield. Less than 3%.........................._.............................. ❑ ❑ -Is there 50 ft or greater between the down 3%to 15%..............._............__......_............. I'� gradient side of Primary dralnfield and 16%to30%...._........._..............._....................... ❑ ❑ property boundary: ��{{ Greaterthan 30%_................._...._....................... El ❑ yes.............................._._......__................................ .__...No............... .............................................................. ❑ ❑ MesofaINXM talanenuatlona lsrequlmdtobere detlwn deetlof Mepmp MWunWilOble �o 1 prior to design approval.Theanenuadommnelsnotrobeusadfar .Memntmoonofroad;decb,pbov, AFN: paAlrq areas,reM1kular trafic.or other similar such use&Theownermurtagmetoolltheseconditluns. r,000sarows, msswwr...aasuwreo arpwaiuwEswwaca%wamerespamwnwama. una+rmarsrzDll Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC Effective Date: July I,2007 Revised April 2017 On-Site Sewage Systems (Chapter 246-272A WAC) Request for Waiver from State Regulations Section 1. (completed by applicant) Name: (1) 11 Local Health Department/District (2) ( .. 0-inelruenaN Address: - r Telephone: (3Ie0) -T S — Signature: vffc Property lden ication: (3) p,* —Z) — '3 UO L VJS '— LLQ ''LLcL Section H. (completed by applicant) WACNumbec (4) WAC Requirement: (5) 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 I 1S"OF V)S FOR GRAVITY OSS Justification(miligation meonrres to be provided); (7) COMPLETED CLASS B WAIVER CHECKLIST ATTACHED, OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN. ZONE AFN: Section ID. (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to(hare proposea): (9) Contracts/Conditions: 00) Type of Waiver: (11) [ ]Class A Class B [ ]Ciess C—Request DOH review before granting? Yes_ No_ Neighbor Notification: (12) Required? Yes_ No_ lfneeded,ore agreements,easements,etc properlyfiled? Yes No _ Section IV. I (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/Grtgmed—Subject to It comments,conditions and requirements noted in Sections II and III. Local Health Officer (13) Data: r r 1 DOH 337-021 Page 26 of 32 2214301 MASON CO WA nalaal2a34 s PM oEc oHW5 MIKEo3 a pYen33i Recl Fee $303 50 Pa es. 1 �IIIIIIIIIIIII1 ItIIIIIII11IIIIIIIIIIIIIIIIIIIII11111IIIIIIIIIIII11I11 Return to: MIKE JOHNSON 1116 WESTCHESTER ST. N.W. OLYMPIA WA 98502 DECLARATION OF COVENANT FOR ON-SITESEWAGEATTENUA77ONZONE 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 Ice simple of(an interest in)the following described real estate situated in Mason County,Stale of Washington;to wit (Division and Lot Number or Range/Township/Section Number. Note:Range,township,section numbers are the 115 digits of the parcel number) L_L S J.3- 6'2- — Z OR 3 a ( _; Subdivision Division Lot Range Township Section and having the Tax Parcel Number of__-22133-21-50002_ on which the grantor(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 grantors)is(are)required to maintain a 50-foot horizontal attenuation zone down gradient of the onaitc 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 grantors)land which might encumber the land set aside for further sewage treatment and disposal. NOW,THEREFORE,the grarm r(s)agrees)and covenant(s)that said gramor(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 y f i 20 Z Signature Signature State of Washington ) County of Mason-) ) 1,the undersigned,a Notary Public in and for the above named County and State,de hereby certify that on this 2.,.a day of 202N , � � a". red personally appea before me, who is known to be igner of the above ins[mmenq and acknowledged that he(she}(they)signed it. GIVEN under my hand and official seal the day and year last above written.Notary G \ ON, z� residing atbli andvfut a State of Washington, =` . y`�.`s .•'. �:' My commission expires: $ r 7 e: "By w B: ''''zzjai�gt7F11111WtPS±` ?