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Home My WebLink AboutWAI2022-00073 - WAI General - 5/20/2022 N CO w At 26202.- 00(13 4 3 Public �� `Health Always working for a safer i healthierhlason County PO Box 1666,415 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: 11' diet) • 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 JIM BRIDGES Telephone 2533154922 Mailing Address of Applicant 21003 117TH ST E City BONNEY LAKE State WA Zip 98391 12-digit Tax Parcel No. 422165300026 -- -- Site Address 10 N BASS PL, HOODSPORT, WA 98548 Subdivision Name and Lot LAKE CUSHMAN #16 TR 26 PART 2: Nature of Waiver/Appeal ❑ Class B Reduction in Vertical Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies 0 Group B Water System Regulations ❑ Location,WAC 246-272A-0210 0 Water Adequacy Requirements IV Holding Tank WAC 246-272A-0240 0 Enforcement Timelines — ❑ Mason County Onsite Standards 0 Departmental Determinations '""""- ❑ Contractor Certification Requirements 0 Other I k >t . (Installer,Pumper,O&M Specialists) 1 MI... `A, ':::? \ Description of Waiver/Appeal(include justification,additional material may be attached.): Install Holding Tank for Recreational/ Part-time Use (RV) By-----€ Meets RSnGs for Holding Tank Design and is on state approved list. Tracking of maintenance through Mason County maintenance database, Carmody Inc. Applicant Signature: J of Date: S /i (,]L. Revised 12/12/2014 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 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 Code/ Standard revision) WAC246-272A-0240(2) 3. Nature of Appeal: ALLOW HOLDING TANK FOR RECREATIONAL (RV)- PART-TIME USE 4. Hearing Official: ❑ Board of Health 0 Health Officer ❑ Pollution Control hearing Board 0 Public Health Director ❑ Certified Contractor Review Board Ell Environmental Health Manager 5. Mitigating Factors: 1. 1200 GALLON TANK, ON WASHINGTON STATE APPROVED LIST OF SEWAGE TANKS 2. INSTALLATION BY A MASON COUNTY CERTIFIED INSTALLER 3. LETTER FROM OWNER AGREEING TO REGULAR PUMP OUTS 4. NOTIFICATION TO FUTURE OWNERS RECORDED ON PROPERTY/PARCEL 5. HIGH WATER AUDIONISUAL ALARM, RISERS TO SURFACE,WATER-TIGHT FITTINGS 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: CD y ` 1 Date: 6 0-0 /27- PART 4: Determination of the Hearing Official It 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: ❑ 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: '7 Date: C/� �/'_-Z- Revised 12/12/2014 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC Effective Date: July 1,2007 Revised April 2017 On-Site Sewage Systems (Chapter 246-272A WAC) Request for Waiver from State Regulations Section I. (completed by applicant) Name: (1) J I M BRIDGES Local Health Department/District (2) (see instructions) Address: 21003 117TH ST E BONNEY LAKE, WA 98391 Telephone: ( ) 2533154922 Signature: - eitrw.„.0............ )11,v Property Ident cation: (3) 10 N BASS PL, HOODSPORT, WA 98548 LAKE CUSHMAN#16 TR 26 Section II. I (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6) 246-272A— 0240(2) holding tank used for pernament holding tank used for part-time recreational use Subsection: commercial uses for RV Justification(mitigation measures to be provided): (7) see local waiver form for full outline of mitigation measures: 1. Design criteria consistent with RSnGs for Holding Tank Sewage Systems 2. Tracking through Online RME (Mason County OSS maintenance database) Section III. (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (10) Type of Waiver: (11) P4-Class A [ ]Class B [ ]Class C—Request DOH review before granting? Yes_ No Neighbor Notification: (12) Required? Yes No_ If needed,are agreements, easements, etc.properly filed? 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 VLApproved/Granted—Subject to all co nts,conditions and requirements noted in Sections II and III. Local Health Officer (13) Date: r%KL y DOH 337-021 Page 26 of 32 Jim Hunter &Associates LOCATION: 2201 "A" 93RD Avenue SW • Olympia, WA 98512-9195 MAILING: P.O. Box 162 • Olympia, WA 98507 (360) 753-1226 • FAX: (360) 705-1360 • EMAIL: jhandassociates@hotmail.com SEPTIC SYSTEM DESIGNERS TO: Mason County Health Department FROM: Jim Bridges REGARDING: Holding Tank pumping acknowledgement 42216-53-00026 DATE: 5/20/2022 To Whom it may concern, Mr. Bridges agrees to have the holding tank pumped as needed,a minimum of once annually. If you have questions please call: 360-753-1226 Jim Bridges 0131051—' gy3 2181940 MASON CO WA 05/20/2022 03:05 PM NOTCE BRIDGES, JIM #175247 Rec Fee: $204.50 Pages III II IIIII III IIII 1 III 1 III II III III I III IIIII III III II III I I I III III1. 2 Return To JIM BRIDGES 21003 117TH ST E BONNEY LAKE,WA 98391 Grantor(s): (1) JIM BRIDGES (2) Grantee(s): (1) PUBLIC Legal Description (1) LAKE CUSHMAN#16 TR 26 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 42216 — _ 53 _ 00026 NOTICE TO FUTURE PROPERTY OWNERS OF RECREATIONAL USE OF HOLDING TANK I (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 has a holding tank installed on this lot for sewage disposal for recreational use only. The approval and permits of the holding tank was conditional to the mitigation required by the state and county waiver process. Failure to maintain the holding tank in the manner required by Mason County Public Health is a violation of these conditions under which the holding tank permit was issued. This could result in abandonment of the holding tank and vacating the property until such time another suitable method of sewage disposal is approved. Dated on this " - day of rn.-/ , 20 --..D. Sign re of Gra ntor(s);_ �,,_ (1) J14A , ^n� S" , (2) State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this i(.Q' day of r\A4 , 2022- , 'SIP" Ilidat.s Orsonally appeared before me, who is known to be signer of the above in trument, and acknowledged that he (she) (they) signed it. GIVEN under my hand and official seal the day and year last above written. c ' &1ci4. Notary Public in and for the State of Washington, residing at efr jLo-k4, to My commission expires: 0i'2-1' 20211 AMBER BRADSHAW Notary Public State of Washington Commission#21008461 My Comm. Expires Sep 27, 2024 Page 2 of 2