HomeMy WebLinkAboutWAI2025-00094 - WAI Health Waiver - 12/29/2025 415 N. 6th STREET,SHELTON WA 98584
F,''' kti,�r SHELTON:360-427-9670,ext 400
MASON COUNTY BELFAIR:360-275-4467,ext.400
_ COMMUNITY SERVICES
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Building Planning.Enwronme,*P Health,Community Health PI
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DEC 2 9
Application for Waiver or Appeal 202�
Amount Paid: 3 Receipt Number: (X0)..'j --CO L ' d4JQ
WAI aUd-5 - 00094
Please note, all approved Onsite Waivers have the same expiration date as their OSS Permits.
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 Information
Name of Applicant (--c-cn 0("i-v , Telephone 3 C9 0' - Y-t-i i - ( 1 b R-
Mailing Address 3 (I ' 1 Qo.0 i ,; e,r-nz-k 7j.
City (2 -t- - State U-I' Zip c1 _2
Parcel No. 2 Z 2 I L. g -- U S'- 0 0 1
Site Address —70 I g_ °'s_3\`,,,,p, `' Ua-,o.• SI , ) 8c` :r Viys C( Y Z�
Subdivision Name and Lot -\CA- (,o uc. I v 4- S
PART 2: Nature of Waiver/Appeal
❑ Onsite: Class A Waiver 0 Food Sanitation Requirements
® Onsite: Class B Waiver 0 Group B Water System Regulations
❑ Onsite: Class C Waiver 0 Water Adequacy Requirements
O Onsite: Location, WAC246-272A-0210 0 Building Permit: EH Review Policies
O Onsite: Holding Tank, WAC246-272A- ❑ Appeal: Enforcement Timelines
0240 0 Appeal:Departmental Determinations
❑ Onsite: Contractor Certification 0 Other
Requirements
Description of Waiver/Appeal (include justification, additional a may k ttt hed.):
Reduce Vertical Separation for Conventional Gravity r Pressure O -
Class B Waiver Checklist
Recorded Declaration of Attenuation Zone
Applicant Signature: Date: f U - 2?--2 S --
Revised 9/29/2025
This form may be scanned and available for public view on the Mason County Web site.
Page 1 of 2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsile 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 Code/ Standard revision): WAC246-272A-0230, TABLE VI
3. Nature of Appeal:
REDUCE_VERIICAL SEPARATION REQUIREMENTS FOR CONVENTIONAL GRAVITY OR
(PRI=SSURE OS '
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Hea th Director
0 Certified Contractor Review Board M' Environme ital Health Manager
5. Mitigating Factors:
CLASS B WAIVER CHECKLIST (MEETS ADDITIONAL REQUIREMENTS OUTLINED WITHIN)
RECORDED DECLARATION COVENANT FOR OSS ATTENUATION ZO VE (AFN 3 O-5)
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: 'Z )'1'\''pCC' `4 Date: -I;o (Z c
PART 4: Determination of the Hearing Official
pa- 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 `indings 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: P' Date: / L/3 0 tJ
Rev xd 9/29/2025
This form may be scanned and available for public view on the Mason County Web site.
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MASON COUNTY MASON COUNTY PUBLIC HEALTH
�1' '''F COMMUNITY SERVICES
%, CLASS B WAIVER WORKSHEET
v Nanning.DrAm mental Health.Community Health
415 N 6TH STREET.BLDG 8.SHELTON WA 98584 (State and Local waiver forms required)
SHELTON 360-427.9670.EXT 400 - BELFAIR 360-275-4467,EXT 400
APPLICANT NAME ^ ) Q 4.-A-I 1 WAIVER PERMIT NUMBER WA
I
MAIINNG ADDRESS 3 16 Ni- O P-t)\S e.r Y"-N. Q-G
CITY (IDA\ Ls.r ///���, . t� STATE ('' (J n z,P grIre k
SITE ADDRESS 7 U 1 ✓`-'�`W"n:C., V I.
c �7* . air 1-1-L\r ry,r
TAX PARCELNl1MSs L'2-2-\ L 0 J 00 I PROPOSED DRAINFIELD TYPE CONVENTIONAL GRAVITY ir CONVENTIONAL PRESSURE
1.SOIL SERIES: 5.VERTICAL SEPARATION:
The soil series must be Alderwood,Harstine,Hoodsport, Up-slope vertical separ8tion 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'_.... . .._._....».».».»._._ .... a Ca
Harstine Gravelly Sandy Loam..................................... ❑ Greater than 18'........._..„.„.„.„....».„.».»».......».......».» ❑
Hoodsport Gravelly Sandy Loam......„..._._...._...._.„. ❑ ❑ -Determined by:
Shelton Gravelly Sandy Loam_..........„„.„....„._...........❑ 0 Depth to hardpan
Sinclair Gravelly Sandy Loam...._...._....................._._.. 0 ❑ Depth to mottling...... ..._._...._._._._».»._.»._. ,„.„_. ❑
Other ...._.__❑ ❑ Both....__...._. ._._._.»»._»._. ._ ... .._._._.»....».„».». ❑ 0
2.SOIL TYPE: 6.WATER TABLE LEVEL:
Soil types must be Medium Sand,Loamy Sand,or Sandy If test holes show evi fence 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._._.__._._._._._._._.__._._...._.......__._._... ❑ ❑ _ -Evidence of seasonal water table:
LoamySand „. ._._._._. ._.__._._._._._. . .__...._..-_.❑ ❑ e Yes. . _. . ._._.__..-_. .,._._. ._._. ......_._._._._._._ _. ❑ ❑
Sand Loam
Percent Gravel: 0 -Curtain Drain required: p
-Less than or equal to 35% 'V UP ro
_._._».»._.»._._.».„. ». Yes._.__. . ._._. ._.__. .,. ._...._._._„.».».».„.»....... _. _. ❑ 0
4.
Si
-Greater than 35%„......„._..........__...._._...._._._......_.❑ 0 3 No...._._......._._. ..._._......_._.„..._...._._._._._._._..._.» _.
3
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3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS:
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to
Soils must be moderately well drained to well drained. 0 Primary Drainfield mus-maintain 200'from down-gradi- m
ent marine shorelir es,surface waters,and wells. 0
z
WellDrained..__...._...._.».»._.„....._.». .........._......_....» ❑ 0
Moderately Well Drained_._... ...._. a 'C -Are Increased horizontal setbacks met:
Other .... ❑ ❑ Yes.................................... .................................................... a
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%.._».»._.„....... .».„_. „,„...... ❑ ❑ -Is there 50 ft or greater between the down
3%to 15% hig gradient side of primary drainfield and
16%to 30% ❑ property boundary: ,
Greaterthan 30%.„_...._._.„._._._.„ ._.... .».»._._. ❑ ❑ Yes. ._._._._._._._._._._._._._._._._._.__._._._._._.__._... E
No.._. ._...._._. ..._.__.».......».».___.»....»..»..»._ ❑ ❑
The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable 7- 2,c O
prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN:
parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. Rooro(Remrdrp:
THIS FORM MAY!iE SCANNED AND AVAILABLE FOR PUNK VIFM ON THE MASON COUNTY WESQTE. updaeed 30/2017
On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations H E A LT H r,
q g
Section I. I (Completed by applicant)
Name: (1) Local Healt1 Jurisdiction Received (2)
c S (See instructions)
Address: Mason County
NE 0( \5 -
(2 e..\.pA :r W a- 18 s-2 is
Telephone: i
- — -- — -- ---
SG - to 1 a-I-
Signature: r r
Property Ide tification: (3)
27? I2 -;S- o -cio l - —
Section II. I (Completed by applicant)
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
246-272A- 0230 24" of V/S for Pressure (12" of V/S for Pressure OSS
,L)
Subsection: Table VI
Justification(Proposed mitigation measures):(7)
Completed Class B Waiver Checklist Attached,(Outlining Additional Requirements Met). Recorded
Declaration OfUoverfalTfor ATTNEZOTle --
Section III. I (Completed by local health officer)
Review Criteria: (8) Additional Mitigation Measures: (9)
Comments/Conditions: (10)
See Class B Waiver Worksheet
Type of Waiver: (11){ ]Class A n Class B f nClass C — Request DOH review before granting? Yes El N25/
Neighbor Notification: (12) Required? YesnNo n If needed, are agreements, easements, etc.filed? Yes Non
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 lea equal to that provided by this chapter WAC.
nDenied Approved/Granted — Subj to all comments, conditions and requirements noted in ections II and III.
Local Health Officer(13) Date: I L/) 2j
DOH 337-175 February 2024
2235303 MASON CO WA
01/02/2026 12:14 PM DECL
LL DAVIS S. SONS #217694 Rec Fee: $304.50 Pages: 2
Return To 1111 IIII 1111 IIIII.I!1111 IIII 1 IIIII 1111111 1111111
1, Sots LLC
Grantor(s): (1) . �!, L/l{V�S� sons C , (2)
Grantee(s): (1) PUBLt,C
Legal Description (1) -A Za--'S 2 � t vioo�A
O� t1�t
(Abbreviated form:r:e. 1 t: bloc , p a or section. township, range)
Assessor's Tax Parcel: (1) 2 7 2 k 2 - ('J 3 . C .0 C) `
DECLARATION OF COVENANT FOR ON-SITE SEWAGE ATTENUATION ZONE
(We) the grantor(s) herein, am (are) the owners in fee simple of (an interest in) the
described real estate situated in Mason County,State of Washington; hereby declare this
covenant& place the same on record;
to wit the described real.estate on which the grantor(s) owns and operates an on-site sewage
disposal system which has been granted a Class B.State Waiver to reduce the Minimum
Vertical Separation requirements and grantor(s) is (are) required to maintain a 50-foot
horizontal attenuation zone down gradient of the on-site 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 grantor(s) land which might encumber the land set aside for
further 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 day of Ark yWav1 .
Page 1 of 2 •
Signa re of Grantor(s):
State of Washington
County of Mason
I,the undersigned, a//N��Notary Public in- and for the above named County and State, do hereby
certify thattnon this bC day of s3�f? 20 a e
�CC� Oc 5 penally appeared before me, who is known to be
signer 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 written.
44\\\\�lu�u lIFni, L e?'tt.� &PAVI.ig
\\\QP .E.ANNF'/"/i Notary Public in and for the St to of Washington,
d` � 202X'�,� 0s residing at
`�°' SARY s m' My commission expires: ip-J —
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