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Home My WebLink AboutWAI2023-00055 - WAI Health Waiver - 5/31/2023 CV C WAI a 1.11•. etcogr 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 : 1-011F �} Amount Paid: Z�ss i MAY 3 1 ZOZ3 Number: y''7 l ReceiptJti, Instructions ._..�.. F3y� 1. Complete Parts I 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 VICTOR HEBERT Telephone 206-919-0439 Mailing Address of Applicant 2401 OLYMPIC AVE NE City RENTON State WA Zip 98056 12-digit Tax Parcel No. 5 1 9 0 1 __ 5 0 _- 0 1 0 5 2 Site Address 1020 W LAKESIDE DR Subdivision Name and Lot PART 2: Nature of Waiver/Appeal ❑ Class B Reduction in Vertical Separation 0 Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations ❑ Location,WAC 246-272A-0210 0 Water Adequacy Requirements ®' Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Onsite Standards ❑ Departmental Determinations ❑ 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 database, Carmody.Inc. Applicant Signature: C, ��,,,,.4 Date: S' .?p Revised l2/12/2014 This form may be scanned and available for public view on the Mason County Web site. Page I oft PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) :72 Appeal V Waiver ❑ None required h/Class A D 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 ' Environmental Health Manager 5. Mitigating Factors: , 1. 1200 GALLON TANK, ON WASHINGTON STATE APPROVED LIST 0,1=SEWAGE TANKS 2. INSTALLATION BY A MASON COUNTY CERTIFIED INSTALLER I 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. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. Staff Signature: ‘\14 Date: c (2e 'Z--- 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: Hearing Official Signature: g.,V Date: ( A�/ 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 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)VICTOR H EB E RT Local Health Departmentl/Dis (2) (see instructio s) • Address: 2401 OLYMPIC AVE NE RENTON, WA. 98056 N w ! l~ y Telephone: ( ) 206-919-0439 I ' 4- Signature: C L 44 ,«//N.) (41.1.1%$) 1 Property Identifi tion: (3) 1028 W LAKESIDE DR 51901-50-010521 Section II. (completed by applicant) WAC Number: (4) WAC Requirement: (5) Waiver f ought: (6) • 246-272A— 0240(2) holding tank used for pernament holding!tank used for part-t me recreational use Subsection: commercial uses for RV Justification(mitigation measures to be provided): (7) see local waiver form for full outline of mitigation m==sures: 1. Design criteria consistent with RSnGs for Holding Tank Sewage Systems 2.Tracking through Online RME(Mason County OSS maintenance database) Section III. I (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those propo ed): (9) Comments/Conditions: (10) Type of Waiver: (11) 14Class A [ ]Class B [ ]Class C—Request DOH review before granting? Y.s_ No_ Neighbor Notification: (12) Required? Yes No If needed. are agreements, easements, etc.properly flu '? 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 246-272• WAC On-Site Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or required,have been eval ated for their ability to provide public health protection at least equal to that provided by this chapter WAC. [ ] Denied Approved/Gr ted—Subject to all comments,conditions and require/m�ents cicited in 'ections II and III. Local Health Officer (13) Dat : U/J (i- DOH 337-021 Pa:.e 26 of 32 2198177 MASON r : Return To 05/12/2023 11:35 PM NOTCE I G, NEBERTY 11187650 Roc Fee: $204.50 Pa es 2 Ii 1I VICTOR HEBERTY 11111111111111111111111111111111111111111111111111111111111111 JUN 1 UU 2401 OLYMPIA AVE NE 2 10Z3 RENTON,WA. 98056 By Grantor(s): (1) VICTOR HEBERT , (2) Grantee(s): (1) PUBLIC 1 Legal Description (1) ! O+ S 2 (�v`Q CAI ' C s+ \ k,e (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 5 1 90 1 _ 5 0 _ 0 1 0 5 2 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 6 day of , 20 Signature of Grantor(s): �� (1) OueLH- � . (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 cer*that on t is w day of 1- - , 20 N1 ickor \ Vk 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 and yea I t above wri`ten. 17t. '--'.1l Notary Public in and for the tate of Washington, KIRA HEBERT I residing at Ek_i-e Notary Pubnic I My commission expires: "-13 J ),,a State of Washington 1` Commission# 209380 1 My Comm. Expires Jul 3, 2023 Page 2 of 2 . j i(s�_ IAA Al 6'r:090./.-_"50 7__4 PY,4 0:2 w , ___ =---------- Atiore 4/ /fee/ec..ree t rki v 1' _.r, CCge) M _A4__Ae_ie- r ..crta/r z _ 44)Axe-Arip ._ fiti ---------. .. •-- -------- --.--74,_-- wise- ls 100/ Ca4 . _______ - r_ g/.r:,, 764w/-de 4—,i ' ag cis -- ._______ . ______________e_ AW___Da___/n.ght_24,_4_e__.__ m,, -_4004 "wolf ------____------- Xo-- 4. - - % �` rn - e/f_ __4._ ' -fir' _pg4"44._ilf 4,04,40/74.m,farrew a: .,, :_._,.... 1, --- -- ------ Rita 'Ai - - --- - --- ray pi , •L. a .-t,- - .._- --- --- 1 --------_--------�' - �4',t --rye -•-� -are -e- VA • ---- __-----_---------------•--_ - -- —K+ +fi --- - -- - - -- Notary Public ----- -------- —Stare-ofWa,Miflgton-- — — — — — — Commission#209380 — — -- ---- —— 023— -- ----_-- ----