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Home My WebLink AboutWAI2022-00082 - WAI General - 6/28/2022 t t staN cou„, Public f Health Always working for a safer ; healthier Mason 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: d 7 °e)Ca Receipt Number:. a a"031 8 Instructions n- 2 r ra' f-O'?t 1. Complete Parts I and 2.No determination can be made until these parts are fully completed. 2. Rees 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 Norma Luviano Gonzalez Telephone 253-312-1580 Mailing Address of Applicant 1431 E. Johns Prairie Rd. City Shelton State WA Zip 98584 12-digit Tax Parcel No. 42017-22-00030 --- Site Address 4471 W Dayton Airport Rd, Shelton,WA. 98584 Subdivision Name and Lot PART 2:Nature of Waiver/Appeal ❑ 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 me Holding Tank WAC 246-272A-0240 0 Enforcement Timelines ❑ Mason County Onsite Standards 0 Departmental Determinations O Contractor Certification Requirements 0 Other (Installer,Pumper,O&M Specialists) Description of Waiver(Appeal(include justification,additional material may be attached.): Install Holding.Tank for Recreational!Part-time Use(RV) Meets RSnGs for Holding Tank Design and is on state approved list. Tracking of maintenance through Mason County maintenance detebasereermeePt4mt Applicant Signatur For applicant Date: 6-28-22 Revised'2/12/2014 This form may be scanned and available for public view on the Mason County Web site, Page I of PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑Appeal flWaiver 0 None required 'Class A 0 Class B 0 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 6 ifEnvironmental 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 AUDIOVISUAL 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: Date: (o ii-,---e) I-2--2_ PART 4: Determination of the Hearing Official Ft-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: Hearing Official Signature: gv7 Date: (/� 671.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 I Effective Date: July I,.2007 Revised April 2017 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) Norma Luviano Gonzalez ._(see instructions)...........__...._....... ........................ Address: 4471 W. Dayton Airport Rd. _..,...,...,.. �.._............_.«......»__«».»..._.................. .,...._......,... ,......».«.... ._...._». Shelton,WAI 9Q584 __-.-«...._......._...._....�.._ .._. Telephone: (253) 312-1580 Signature: ..1. 9For applicant Property Identification: (3) 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 fay 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 _...___w.._...........«...«. . . __«« »«.w — , 2.Tracking through Online RME(Mason County OSS maintenance database) Section III. i (completed by health office?) Review Criteria: (8) Mitigation Measures(in addition to those proposed) (4).. rrontmcnts/nConditiotis' '(IR),. _........ ...._ ........ _.... __...... «...««».»_,. _, «», ....«... _,.,......«.......... ,. _..»_�_ ... Type of Waiver: (11) 4-Class A [ ]Class B I. I.Class C—Request DOH review before granting? Yes __. No Neighbor Notification: (12) Requited? Yes_ No_ lfneeded,are 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 WAG 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 provide by this chapter WAC. [ ] Denied 4Approved/Granted—Sub' to all comments,conditions and requirements ted in Se Lions II and III. Local Health Officer (I3} I Date: 6/ c d Z Page 2(i of 32 DOH 337-021 1 ft„ Benjamin Valdes Norma Luviano Gonzalez 4471 Dayton Airport Rd, Shelton, WA. 98584 (253) 312-1580 To whom it may concern, We agree that the proposed septic holding tank for our property address above will be pumped as required on a regular basis. We agree it will be maintained in good standing at all times. Thank you, Benjamin Valdes / Date (7"-- u�, ...�.*-t Date . 0 �. Norma Luviano Gonzalez �Jov' °1 t ni'f h '4„ F 2183114 MASON CO WA 06/14/2022 11:38 AM NOTCE Return To GONZALEZ #176098 Rec Fee: $204.50 Pages: 2 j,vvrRn� IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII \\)�Y�it onzae I4 i. 3oti,k5 'Ncc;v‘ ' . THIS IS NOT AN ORIGINAL DOCUMENT Grantor(s): (1) Norma Luviano Gonzalez ,(2) Graiitee(s): (1)PUBLIC Legal Description(1) Tr 3 of N 1/2 NW See Survey 10/40 \K4 (Abbreviate t form:i.e.lot, block plat or section, township, range) Assessors Tix Parcel: (1) 42017-22-00030 _ 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. Failur9 to maintain the holding tank inthe.manner required by Mason:County'Public Health is a violation of these cOnditio.ns under°which the holding tank permit was issued.This cupid result in abandonmentOf the'holding;tank and vacating the property until such time another suitable method of sewage disposal is approved. Dated on this COday of 1 ,20 Signature Of Grantor(s): State.of Washington County-cif Mason U y,� r 1..� n Page 1 of 2 �i t L 1 JUN 2 4 2022 t ` I,the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this Ct day of3s ' _ ,207 Z , nor r•A l w61)0G-nrie 2t cZ . personally 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 an. year last above Wr en. 111 LISA MWOODARD Notary Public in'and for the State of Washington, NOTARY PUBLIC#53326 residing.at-9 le_,\k STATE OF WASHINGTON My commission expires: "` '1 — 4 COMMISSION EXPIRES AUGUST 29, 2025d Page 2 of 2