Loading...
HomeMy WebLinkAboutWAI2026-00033 - WAI Health Waiver - 5/28/2026 415 N.6"STREET,SHELTON WA 98584 • SHELTON:360-427-9670, • MASON C NT BELFAIR:360-275-4467,ext.400 Public Health & Human Services t5 �� 26 Application Application for Waiver or Appeal 8y Amount Paid: 4f Receipt Number: a lo� WAI o 2c3 3 oa 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 belted for wavers and appeals,based on the Environmental Health Fee Schedule 3 Submit completed application with attachments to Mason County Public Health for review. ` ... .F PART 1.Applicant& Parcel Information Name of Applicant Daniel Block Telephone (253) 625-1520 Mailing Address 1220 N I St city' Tacoma State WA dip 98403 Parcel No. 1 2 20 7 _ 7 5 _ 0 0 6 4 0 Site Address 300 E Tepee Ln, Belfair, WA 98528 Subdivision Name and Lot TR 64 OF SURVEY 5/94-96 PART 2: Nature of WaiverlAppeal ❑ Onsite: Class A Waiver O Food Sanitation Requirements ✓❑ Onsite: Class B Waiver ❑ Group B Water System Regulations ❑ Onsite: Class C Waiver ❑ Water Adequacy Requirements ❑ Onsite: Location,WAC246-272A-0210 ❑ Building Permit: EH Review Policies ❑ Onsite: Holding Tank,WAC246-272A- ❑ Appeal:Enforcement Timelines 0240 ❑ Appeal:Departmental Determinations ❑ Onsite: Contractor Certification ❑ Other Requirements Description of Waiver/Appeal(include justification, additional materi a d.): Reduce Vertical Separation for Conventional Grave or Pressure OSS Class B Waiver Checklist Recorded Declaration of Attenuation Zone Applicant Signature: Dater Revised 03/03/2026 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 a n PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑Appeal p Waiver ❑ Class A IZiClass B 0 Class C 0 Local State Waiver Criteria ( 05CNO Number of Bedrooms: 15Nitrogen Treatment: ❑Yes Soil Type: (4 Minimum Lot Size: ` a Grp Water Source:❑Public MPrivate This Lot Size: •1S t - ls This Lot Eligible for State:Waivers: Yes 0 No ❑ N/A Hearing Official: 0 Environmental Health Manager ❑ Public Health Director ❑ Other: 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 or Pressure OSS 5. Mitigating Factors: Class B Waiver Checklist (Meets additional requirements outlined within Recorded Declaration Covenant for OSS Attenuation Zone (AFN ) 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: 7% PART 4: Determination of the Hearing Official .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: 7 6 9 Revised 03/03/2026 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 MASON COUNTY MASON COUNTY PUBLIC HEALTH COMMUNITY SERVICES CLASS t�A1VER VV®RI(SHEET Building,Planning,Environmental 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:36O.275-4467,EXT.400 APPLICANTNAME ��y�y` \® WAIVERPERMITNUMBER WAI MAIUNGADDRESS IZZ0 ` CITY -Vf CC)MA STATE 'T ! ZIP _ l o� SITE ADDRESS -J00 E w4 ciTY TAX PARCEL NUMBER L'1 1 D -15 ~ oo(pit) PROPOSED DRAINFIELDTYPE O CONVENTIONALGRAVRY 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................................❑ 0x Greater than 12"................................................................ ` Harstine Gravelly Sandy Loam ❑ D.. Greater than 18"............................„.................................. ® :O Hoodsport Hoodsport Gravelly Sandy Loam................._............. ❑ 4 i -Determined by: Shelton Gravelly Sandy Loam........ ... ...............❑ Depth to hardpan............_......-....................................... ❑ Y Sinclair Gravelly Sandy Loam................_......._.............❑ 0 Depth to mottling..................._..................................... OtherIKV EA ii S GSt.. Both............................_........_............_................................. � 2.SOILTYPE: 6.WATERTABLE 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 -. e �e Medium Sand................................................... ❑ ❑ -Evidence of seasonal water table: -❑ ❑ ❑hy "a Yes.........__..............................................._............ ........_.... ❑ Loamy Sand '` "` Sandy Loam No ...................................._.............�' < .__................»................................................ f :n p -Curtain Drain required: H �Q Percent Gravel: " x 1, Lessthan or equal to 35%..._......... ....................._ ❑ a- Yes........................................_..........._............_............._...... ❑ ❑ �. �, -Greater than 35%.........................................................❑ ��� No.................._................................................_......_............ 3.SOIL DRAINAGE: 7.HORIZONTAL SETBACKS: Soils must be moderately well drained to well drained. C7: Primary Drainfield must maintain 200 from down-gradi- ent marine shorelines,surface waters,and wells. WellDrained....... ................................................................ . Moderate) Well Drained ❑ w -Are increased horizontal setbacks met: y .............................................. Other ❑ Oz4z Yes.......................................................................................... ti� v No............................................. ........................... .............. 0❑ Q 4.DRAINFIELD SLOPE: �� 8.ATTENUATION ZONEg Slopes must be between 3%to 30%. asa Gravity is only allowed on slopes from 3%to 15%. F A 50 foot horizontal attenuation zone is required fi x Pressure is allowed on 3%to 30%. c down-gradient of the primary drainfield. Less than 3%..........-.................................._..... ❑ -is there 50 ft or greater between the down 3%to 15%............................................._........_........_.._.. F, � gradient side of primary drainfield and 16%to30%................................_. .. ❑ © property boundary: Greaterthan 30%........_............................................... ❑ ❑ � Yes.._......._........................._......................_..........._...._.... . ..................................................................... ❑ a❑ The 50 foot horizontal attenuation zone is required to be recorded on the deed of the property as unbuildable a ZGl `� prior to design approval.The attenuation zone is not to be used for the contruction of roads,decks,patios, AFN: L parking areas,vehicular traffic,or other similar such uses.The owner must agree to all these conditions. ProofofRecording: THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLICVIEW ONTHE MASON COUNTY WEBSITE updated 322077 Washington Slate[Inpdrtmant af' On-Site Sewage Systems (Chapter 246-272A WAC) Request for Waiver from State Regulations ecan 1 „a r (Completed by applicant) "J.�ocal Health Jurisdiction Received(2) Name.(1) Daniel Block (See instructions) ............._..........___-______-_-____•-•----•---•-.._...._.._.-._... `� a .^ws Address: 1220 N I St, Tacoma, WA 98403 Mason County 6J Telephone: ( 3) 625 1520 as -__'___•____---••---------------••----. .y `z.rs r '" 4 r'� ?`v .y i ` .rx 7 }4K Signature Property Identification:(3) TR 64 OF SURVEY 5/94-96 ----•------------------------------ Parcel#12207-75-00640 (Completed by applicant) WAC Number:(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 18"of V/S for Gravity O SS Justification(Proposed mitigation measures):(7) Completed Class B Waiver Checklist Attached,(Outlining-Additional Requirements Met). Recorded •- Declaration of Covenant for ATTN. Zone (AFN: 1929012 (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 Y Class B Class C— Request DOH review before granting? Yes No Neighbor Notification:(12) Required?Yes❑No❑ If needed,are agreements,easements,etc.filed? Yes No (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 Jf Approved/Granted—Subject to II comments,conditions and requirements noted in Se i�olns II and Ill. 11L�• Date: v� Local Health Officer(13) 1 DOH 337-175 February 2024 1929012 MASON CO WA 1010N23655 Re c Fae: $42.00 P e : IlWl�l91���1�1��l�llllil��lfll�l��lll� lIUI1�ft�l Return to: Eric & Wanda Simon NE 60 Fir Lane Belfair, WA 98528 IDECL 4RAT IONOF COVENANT FOR ON-SITE SEWAGE ATTEENUATIONZONE 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 fee simple of(an interest in)the following described grantor)grantor)real estate situated in Mason County,State of Washington;to wit:(abbrev d mat desu'ptioc�o p opaar owned byTR 64 of Survey 5/94-96 R1W Twp22N Sec07 and having the Tax Parcel Number oft 12207-75-00640 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 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,TIiEREFORE,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 a as a{�co�r conduit for migrating ground water. WITNESSrhand this day of u 20 gnature Signature State of Washington ) County of Mason ) I.the under i tart'Public in fo a named fate,do hereby certify that on this day of ,20 01'LttL ! Q rally appeared before me, who known to be signer of the above instrument,and acknowledged that he(she)19)signed it GIVEN under my hand and official seal the day and year last above State of Washington, �• :'�' e,,t�j, residing at '��°,.'�-AR�„"_.d_ Mycommissionexpires: c V rWASH\