HomeMy WebLinkAboutWAI2023-00053 - WAI Health Waiver - 5/24/2023 t� l ILA eccnS`3
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Public \.‘.. -4-0-Health
Always working for a safer t..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 6)17: r ' nn �
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Amount Paid: 4 1.%5 , ^ I J
i;,• Y
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 Vet/ f- Je•J(i(.l Telephone„TO 7 (16o7
Mailing Address of Applicant P. D 36x 367
City L 1 (1 v State 0-41 , Zip L g 3-55
12-digit Tax Parcel No. 3 3 I 6 -- S -- 6 p Z 3
Site Address vuap/Q t,,v� .
Subdivision Name and Lot r�9023 R, 3 c.J, c,JI-(, /o./.
0,23
PART 2: Nature of Waiver/Appeal
❑ Class B Reduction in Vertical Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Location,WAC 246-272A-0210 0 Water Adequacy Requirements
I9' Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Contractor Certification Requirements ❑ 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: - Date:
This form may be scanned and available for public view on the Mason County Web sitesed 12/12i2014
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 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 ❑ Public Health Director
❑ Certified Contractor Review Board El 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: Date: 12-I 25
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: AGV Date: (42 2/J
ReviThis form may be scanned and available for public view on the Mason County Web site.
12/12/2014
Page 2 of 2
.. �1 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) •
�o �'i Local Health Department/District (2)
..... . _ (see inst uctions�
Address: -- _____ �.._.._.....__._
P a Bint 367
l,.`.I.I c.Op......Oct.� 9 g 555
Telephone: �_............. _ _._ _..........._.._........__._._.______._....__: M_._._.___._.
Signature: __..._............ ___....._.. ...___ __.__.
S" 23 23
Property Identification: (.
Section II. I (completed by applicant)
WAC Number: (4) WAC Requirement: (5) Waiver Sought: (6)
246-272A— __._............._......_..........._........._._.........._............
0240(2) holding tank used for pemament 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 office?)
Review Criteria: (8) Mitigation Measures(in addition to those proposed):
Comments/Conditions: (10)
Type of Waiver: (11) ,aClass A [ ] Class B [ ] Class C—Request DOH review before granting? Yes No
Neighbor Notification: (I12) 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 14Approved/ Granted—Subje o all comments,conditions and requirement noted in Sections II and III.
Local Health Officer (13) Date: C
2-2_ Z- I
DOH 337-021
Page 26 of 32
2197473 MASON CO WA
05/24/2023 11:06 AM NTFCL
Return To DOUG DEVLIN 1187116 Rec Fee: $204 50 Pages: 2
Illlffl IIIIII NII 111111111111111111111111111111111111111111111111111
Dade # iJed l;
70 &CA 367 L�IIi�Jatip
'z(7555
Grantor(s): (1) 1,06 cl G ( ,--,}2) , (2)
Grantee(s): (1) PUBLIC �J
Legal Description (1) Sec. 1, i-LJ^! A3►J R 3 t-a bit-{, t-c94. ot3
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3,_ c(. 3_ I 6 - 5 d _Q d L. 4 A- 3
NOTICE TO FUTURE PROPERTY OWNERS OF RECREATIONAL USE OF HOLDING TANK
I (We), the undersigned grantor, hereby place this notice on record that the described real
estate situated in Mason County, State of Washington; to wit the described real estate has a
holding tank installed on this lot for sewage disposal for recreational use only.
The approval and permits of the holding tank was conditional to the mitigation required by the
state and county waiver process. Failure to maintain the holding tank in the manner required by
Mason County Public Health is a violation of these conditions under which the holding tank
permit was issued. This could result in abandonment of the holding tank and vacating the
property until such time another suitable method of sewage disposal is approved.
Dated on this 2 3 day of 1.41 -/ 20.2.3.
ignature of Grantor(s .
(1) ( , (2)
State of Washington
County of Mason
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
Toy that on this c day of t _p , 2001. ,
IGS 'i •• LV I(r ) rsonally appeared before me, who is known to be
signer ofthe above instrument, and she acknowledged that he (they)(she) (# ey) signed it.
GIVEN under my hand and official seal the day and year last above written.
�;�Q�A miss �C,f_. Notary Publi Jilat in and r the State of Washington,
?o - residing S 11CI
. .,0 °$-o� �.' at
� � i°T=yam'y:off My commission expires: j tT/,-2U,(to
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Page 2 of 2
r r
May 30, 2023
Mason County Community Services
Shelton,WA 98584
RE: Septic Holding Tanks Parcel#32316-50-00022 & Parcel #32316-50-00023
To Whom it May Concern:
I am writing this letter to confirm that I am placing two septic holding tanks one per parcel on the above
mentioned lots.
I am agreeing to have them regularly pumped according to the design and use recommendations. This
agreement has also been registered for future property owners as recorded with Mason County Auditor
#2197472� on May 23, 2023.
Sincerely,
Mr. Doug Devlin