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Home My WebLink AboutWAI2023-00100 - WAI Health Waiver - 9/16/2023 Loa- 1 O c) ( o d • ,SON COtm, • Public rill 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/AppealQ Amount Paid: � C) S - 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 JOSE BORRAYO Telephone 360-536-6827 Mailing Address of Applicant S6 Qa iFettper Va/r "Ave.,"rh L✓4 1 City CA i — -- State Zip---qf3.Z1/45-. 12-digit Tax Parcel No. (52 -- Site Address 941 N POTLATCH RD, HOODSPORT, WA. 98548 Subdivision Namc and Lot PART 2: Nature of Waiver/Appeal ❑ Class B Reduction in Vertical Separation ❑ Building Permit Review Policies ❑ Food Sanitation Requirements 0 Group B Water System Regulations ❑ Location,WAC 246-272A-0210 LB' Holding Tank WAC 246-272A-0240 0 Enforcement 0 r Aden Ti Requirements ❑ Mason County Onsite Standards Timelines 0 Departmental Determinations ❑ Contractor Certification Requirements El 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: L., L.) 162_4 ,�,i f s fl ./,... Date: 9/ /6 This form may be scanned and available for public view on the Mason County Web site.Revised 12/12/2014 Page 1 of 2 PART 3: Public Health Evaluation (Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑ Appeal it/Waiver None required s/Class A u 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 ❑ Certified Contractor Review Board 0 Public Health Director her 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: Datc: -_/I /z/207I -- -- PART 4: Determination of the Hearing Official [IL-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: 4114 l/ 3.17Z1 ----— Date: I This form may be scanned and available for public view on the Mason County Web site.Revised 12i12i2014 Page 2 of 2 ai - i 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. I (completed by applicant) Name: (1) IOSE BORRAYO Local Health Department/District (2) Address: •J (see instructions) S-4 90 _Ben?vet V_(i ey 1?/ C4 ,'en a cu y 7 ryzr Telephone: ( ) 360-536-6827 Signature: L"..-2: ' .•/ Y /1„4.p Property Identifi ation: (3) 42318-51-00086 2.31.k NCI - cf Y .� ` (4. cdr l ��l�e:� r� ,Ot.ti Section II. I (completed by applicant) '�` -1 4,f WAC Number: (4) WAC Requirement: Waiver Sought: (6) 246-272A— (5) 0240(2) holding tank used for pernament holding tank used for part-time recreational use Subsection: commercial uses for RV Justification(mitigation measures to he 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. I (completed by health officer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (10) Type of Waiver: (11) [y) Class A [ ]Class B [ ] Class C—Request DOH review before granting? Yes_ NoX Neighbor Notification: (IV Required? Yes No X If needed. are agreements, easements, etc.properly/i/ed? 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 [ pproved/Grante --Subject to all comments,conditions and requirements noted in Sections II and Ill. Local Health Officer (13) (l {3 rl Date: DOH 337-021 Page 26 of 32 09-29-2023 To who it may concern, I Jose borrayo and Jillian borrayo own the property on 941 n potlatch st, we are installing a holding tank for are camping trailer. We promise to have the tank pumped at least once a year and serviced as needed. Thank ou Jos lay% iaa