HomeMy WebLinkAboutWAI20025-00003 - WAI Health Waiver - 1/16/2025 MASON co„„,
Public �0 Health
Always working for a safer . healthier Mason County
415 N 6th Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 •:• Belfair:(360)275-4467 ext 400 ❖ Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid: $305.00 Q GOQ3
Receipt Number: rX$.5 -oc 33U
Instructions
I. 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 Susan Watt Telephone 503-201-3977
Mailing Address of Applicant 7520 N Mohawk Ave Apt B
City Portland f State OR Zip 97203
12-digit Tax Parcel No. ( �. 3 I 5 -- 7 5 -- & O 0 ( 0
Site Address No Address on Capstan Rock Rd
Tract B of BLA#22-05 AFN 2181512
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
)S71 Class B Reduction in Vertical Separation 0 Food Sanitation Requirements
O Building Permit Review Policies 0 Group B Water System Regulations
❑ Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
D Mason County Onsite Standards 0 Departmental Determinations
❑ Contractor Certification Requirements 0 Other
(installer, Pumper,O&M Specialists)
Description of Waiver/Appeal (include justification,additional material may be attached.):
Reduction of Vertical Separation from 36"to 18" ALDERWOOD series soil, sandy loam with<35%
gravel. Well drained, slope>3%, able to maintain 18" separation over water table
No surface water or wells within 200' down gradient from drain field � ' ZZZZ 1�l,
I nt is hig Pnni iah to maintain S0' attenuation 7nne(-lows gradient_tram primary nF 7
•
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Applicant Signature: L � ��� Date: / �6 —
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1:\EH Forms\Waiver-Appeal Ma.son County local Revised 12/1/15
Page 1 of 2
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 !'Class 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 6R
4. Hearing Official:
❑ Board of Health 0 Health Officer
O Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board 6' Environmental Health Manage
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST (MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN)
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZONE (AFN ?Z ZZ(L?
6. I have received this waiver/appeal request. It is complete and mitigation required by the
state and local policy has been submitted.
Staff Signature: Date: (3 / 2r
PART 4: Determination of the Hearing Official
A.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:
0 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: Z l I /2o1
S
Rcvised 8/21/2017
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
tivvsoN CO, v�T
MASON COUNTY PUBLIC HEALTH
Public ----„:.7 Health CLASS B WAIVER WORKSHEET
Always working for a safer : healthier Mason County (State and Local waiver forms required)
PO Box 1666,415 N 6th Street,(Bldg 8) - Shelton WA,98584
Shelton:360-427-9670 ext 400 Belfair:360-275-4467 ext 400 APPLICANT NAME Susan Watt WAIVER PERMIT NUMBER WAI 20 Z$" Oa / n
/0 J
MAILING ADDRESS 7520 N Mohawk Ave Apt B tJ
CITY Portlanci
STATE OR ZIP 97203
SITE ADDRESS No Address Capstan Rock Rd CITY Tahuya
TAX PARCEL NUMBER 32315-75-00090 PROPOSED DRAINFIELD TYPE N CONVENTIONAL GRAVITY 0 CONVENTIONAL PRESSURE
1.SOIL SERIES: 5.VERTICAL SEPARATION:
The soil series must be Alderwood,Harstine,Hoodsport, Up-slope vertical separation must be greater than 18"
Shelton,or Sinclair Gravelly Sandy Loam. for gravity and greater than 12"for pressure.
Alderwood Gravelly Sandy Loam ❑ Greater than 12" 0 0
Harstine Gravelly Sandy Loam ❑ U Greater than 18" El tiii
Hoodsport Gravelly Sandy Loam 0 ❑ -Determined by:
Shelton Gravelly Sandy Loam ❑ 0 Depth to hardpan 0
Sinclair Gravelly Sandy Loam ❑ 0 Depth to mottling ❑
Other ❑ ❑ Both ❑ igl
2.SOIL TYPE: 6.WATER TABLE LEVEL:
Soil types must be Medium Sand,Loamy Sand,or Sandy If test holes show evidence of a seasonal water table
Loam.Gravel percent must be less than or equal to 35%. above restrictive layer,a curtain drain may be required
Medium Sand 0 0 -Evidence of seasonal water table:
Loamy Sand ro
54 01 s No RI IN
CI
Sandy Loam
Percent Gravel: tp
-Curtain Drain required: El 0
-Less than or equal to 35% ICI o Yes
-Greater than 35% Elg No CZ In ^
m
3. SOIL DRAINAGE:
7.HORIZONTAL SETBACKS:
rD F.
Soils must be moderately well drained to well drained. , O Primary Drainfield must maintain 200'from down-gradi- O
ent marine shorelines,surface waters,and wells. _
Well Drained ® I
Moderately Well Drained 0 0 -Are increased horizontal setbacks met:
Other 0 0 Yes
No 0 ❑
4. DRAINFIELD SLOPE:
8.ATTENUATION ZONE
Slopes must be between 3%to 30%.
Gravity is only allowed on slopes from 3%to 15%. A 50 foot horizontal attenuation zone is required
Pressure is allowed on 3%to 30%. down-gradient of the primary drainfield.
Less than 3% 0 0 -Is there 50 ft or greater between the down
3%to 15% 17J U gradient side of primary drainfield and
16%to 30% 0 0 property boundary:
Greater than 30% ❑ ❑ Yes
No ❑ 0
The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable
prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: 27-7,117,
parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Proof of Recor og:
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE. , updated 2/2/201 S
144
Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WA `f[Jam/
Effective Date: July 1.2007 Revised April 2017 c5
•
On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations
Section I. I (completed by applicant)
Name: (1) Local Health Department/District (2)
S c/a ,3,✓ /1 Tr (see instructions)
Address: //0501
CO
�7s1..v N no/- iVr 4�t.E (•O(/f 1'y
tU2 y7 03
Telephone: ( c;•T a / - 9 7 7
Signature:
Property Identification: 0)
vC Se. SE s .SVA3v..-7...!3
3Z3 is- 7.5 000 �o
Section II. I (completed by applican()
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
246-272A---- 0230 ) 1
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,
(OUTLINING ADDITIONAL REQUIREMENTS MET). RECORDED DECLARATION OF COVENANT FOR ATTN.
ZONE (AFN: Z Z Z Z 1 Z I )
Section III. (completed br health 6i1icer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Conditions: (10) fee. q sC/eted C'/A,$ e War Imo- tr,7c/C.a
Type of Waiver: (/1) I ]Class A 'Class B ]Class C----Request DOH review before granting? Yes No x
Neighbor Notification: (12) Required?(Yes No if needed,are agreements. easements, etc.properly fled? Yes _ No
Section IV. J (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.
J Denied Approved/Granted - Subj• o all comments,conditions and requirements noted in Sections 11 and Ill.
' 1I 7S`
Local Health Officer (/3) Date: Z (l ( Z
DOH 337-021
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2222129 MASON CO WA
02/27/2025 03 57 PM DELL
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Grantor(s): (1) Su 5.1,y h1 \• .)) , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) Ti2 B if?LA Z2--GS- Af# Z)B/Si,
(Aviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1aNN .?/23 1 S- -7 .S`- 0 0 0 .9 O
DECLARATtt VENANT FOR ON-SITE SEWAGE ATTENUATION ZONE
I (We) the grans he;ei;am (are) the owners in fee simple of(an interest in) the
described real tate s3tated in Mason County, State of Washington; hereby declare this
covenant 881:ite.\theilile on record;
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to wit t4eSCribed'real estate on which the grantor(s)owns and operates an on-site sewage
dispOal sySiem which has been granted a Class B State Waiver to reduce the Minimum
Vef cal$eparation requirements and grantor(s) is (are) required to maintain a 50-foot
hot o_r` al attenuation zone down gradient of the on-site sewage system to facilitate
% [of the sewage effluent.
t is } purpose of these grants and covenants to prevent certain practices hereinafter
ofnerated in the use of the grantor(s) land which might encumber the land set aside for
rther sewage treatment and disposal.
- NOW, THEREFORE, the grantor(s) agree(s) and covenant(s) that said grantor(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_ 21 day of F Fog. ,A , 20 '2-c .
Page 1 of 2
s
Signature of Grantor(s):
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(1) wv , (2)
a L
State of W>elshington Q g 6(2,00 ) O
County of - Nut,.-r -F norvIa )
1, the undersigned, a Notary Public in and for alb v n ed County and State, do hereby
certify that on this 21- day of . , 20!2S ,
5ucQSn u C,t_'(c person _ 04,ared before me, who is known to be
signer of the above instrument, and ackrtiwledg that he (she) (they)signed it.
GIVEN under my hand and official seal tt day ctd y arias ve written.
0
Notary Public in and or the State of-Washirngteri,o ch
s t'. OFFICIAL STAMP �j
. , , LILIANOELLETRuE._ residing at 241g4 u. l.Ca' D(S-r‘5,`cT(P41DQ
4 0 Ngat Iss o 1;.1 76 My commission expires: 0 1 09202R 213
MY COMMISSION EXPIRES T 7028
0
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2222129 Page 2 of 2 02/27/2025 03:57:19 PM Mason County, WA