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Home My WebLink AboutSWG Inactive OFFICIAL USE ONLY MASON COUNTY WTEMHED: 3_ _ 2 H D COMMUNITY SERVICES F� _ BKFNFD c N N al PubB[XeIM ICommunhy HealXVFmi nmenlal HzaltM O y swG �a _ Go Z s A a W.,eM ON-SITE SEWAGE TANK ONLY APPLICATION 3 p PPPIILANT PHONE rn rn r SHARON DILL 3608772042 z c MAILING ADDRESS-STREET.CRY STATE.LP CODE 3 PO BOX 337, HOODSPORT,WA 98548 m A SITEP➢DRE63-STNEET CT',DP CODE L�. 180 N DUCKABUSH DR W,HOODSPORT,WA 98584 l^ NAME OF DESIGNER I PHONE h ADAM HUNTER 3607531226 �`f+ NAME OF INSTALLER PHONE O ROYALFLUSH TPEOFWORKP[ t—) DRINKING WATER SOURCE y IO NNEWCONSTRUCTIONIURGRADES OREPAIRIREPLACEMENT 13 PRNATEINDIVIDUALWELL OPRIVATETWPPARTYWELL S I� 0 PUBLIC WATER SYSTEM LAKE CUSHMAN I I COIAPIXiENTISITO BE flEFLACE01 INSTALLEDI O SEPTIC TANK [3PUMP TANK ERV HOLDING TAN( BEDROOMS LOTSRE 111 Z/ -p I(p O OTHER WA D.26 OTHERDEFARSD*W40,&ep,My) TANNS)SETBACK CHECKLIST r SURFACING SEWAGE [3 DUSTING FAILURE O SHORELINE 100FT•PUBUCV COMMUNNY WELLS 0 SUSMITT/LL6 . SDFT•PRIVATE WELLS,SURFACE WATERS STREAMS.MI RS C, PLOT PLAN(REQUIRED) O TANK CROSS SECTIDN(REQUIRED) ■ tOFT•DRINKING WATER SUPPLY LINES b O PUMP DETAILS(IFAPPLICABLE) MWANER(S)(IF APPLICABLE) � SFT•PROPERTY/EASEMENT LINES,FOUNDATIONS,FOOTINGS AJ PLOT PLAN CHECKLIST Q p ® PROPERWLINESANDEASEMENTS NEXISTINGIPROPOSEDSTRUCTURES OEXISTING/PROPOSED OSS COMPONENTSAND LINES G WELLS WITHIN 100FT S WATER SUPPLY LINES EDRIVEWAYSIPARKING 0 SURFACE WATERS,STREAMS,RIVERS,ETC— I I� ■ DIRECTION OF SLOPEICONTOURS 13PERIMETERICURTAINDRAINS ®NORTHARROW MSCALEBAR ( A. ORECTION9 T0911EPNDSf1E CONgTN)NS:(ea.buYei paN) N� LAKE CUSHMAN TO A LEFT ON DUCKABUSH TO A RIGHT ON DUCKABUSH TO SITE ON THE RIGHT. �„^,'; 1 G —�--j OFFICIAL USE ONLY BELOW THIS LINE UPGRADE I FNLVRE SOURCE Bw i mnB Rv P ) OVOLUNTARY [3MAINTENANCEIPUMPING OBUILDINGPERMIT 13HOMESALE QGOMPLMNT 13OTHER: COMMENTS/CONDITIONS SEWAGETANKS MUST BE LISTED UNDER WH LSTOF REGISTERED SEWAGE TANKS-+TANKS MUSTMEETCURRIENT MINIMUM SIZE REQUIREMENTS.EQUIPPED WITH RISERS AND IIDSTO SURFACE.AND INCLUDEAN EFFLUENT MLTER IIFAP%M.ABIE). RECORDORAWINGANDINSTAGATKINREPORTREQUIREDFORFINALAPP AL. INSPECTORSIGNATURE DATE AP0.IGTIONEXPIRACONDATF APRIGTgNAPPROVEDII$$UEO BV CATE THIS FORM MAY BE SCANNEDANDAVABABLE FOR PUBMVEWONTHE MASON COIINTYWEBSTTE REVISED 07AS1019 S � & 2 - | . - § ! ! § ; _ { { . ■ . � �� ! } ) !,9 v9we , J -/!h/! ! ; g«! ■�!� � � \ \\\q � R|\ / _/ ) ` . § ) / ¥ - ■ , R ! \ b gl�i - y \ k/ \ / 44\! / / � "4,PSON COUNZ e.A& 1 J L7 a.Ly _. 00cm0�C7 Public'qHeaM Always wodong for a safer healthier Masan County PO Box 1666,415 N 6t°Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 {e Belfair:(360)275-4467 ext 400 G Elma:(360)482-5269 ext 400 FAX (360)427-7787 I Application for Waiver/Appeal Amount Paid: Receipt Number: ezz� _J Instructions J 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 Envirmunamal Health Fee Schedule. 3. Submit completed application with attachments to Mason County Public Health for review. PART 1.Applicant/Parcel Identification Name of Applicant SHARON DILL Telephone 3608772042 Mailing Address of Applicant PO BOX 337 City HOODSPORT State WA Zip 98548 12-digit Tax Parcel No. _ 42204 _ _ -- 51 _ _ _ 00013 Site Address 180 N DUCKABRUSH DR W, HOODSPORT,WA 98548 Subdivision Name and Lot LAKE CUSHMAN #6 TR 13 PART 2: Nature of Waiver/Appeal ❑ Class B Reduction in Vertical Separation ❑ Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Group B Water System Regulations 0 Location,WAC 246-272A-0210 13 Water Adequacy Requirements d Holding Tank WAC 246-272A-0240 O 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 Signattue: Date: 3Q2124 Revised 12/12/2014 This form may be scanned and available for pu view 0 th Mason County Web site. Page I oft PART 3: Public Health Evaluation(Staff Use Only) I. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑ Appeal V 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 ❑ Health Officer ❑ Pollution Control hearing Board ❑ Public Health Director ❑ Certified Contractor Review Board 91' 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 PROPERTYIPARCEL 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: 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: 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: - \ � � DD.� n y- s or- fr ,- o3Zo CS (e I l I Hearing Official Signature: Date: 1-4 3 Q2T Rev ed 12/12/2014 This form may be scanned and available for pu is 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) Re uest for Waiver from State Regulations 9'�Y^ `. (completed by applicani) Name: (1) SHARON DILL Local Health Department/District (2) (see instructions) Address: PO BOX 337 HOODSPORT, WA 98548 ..........- Telephone: ( 36 20 S gnatur Property ldenti ran: (3) Section U. (completed by applicant) WAC Number: (4) WAC Requirement: (3) Waiver Sought: (6) — 246-272A— 0240(2) holdi tank used for pernament holdi tank used for part-time recreational us 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 .....__—.-... -.....9 -........... ( ) 2.Trackingthrough Online RME Mason CountyOSS maintenance database Simon�, (completed by health ofcer) Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9) Comments/Conditions: (Id) Type of Waiver: (11) [ ]Class A t ]Class B [ ]Class C—Request DOH review before granting? Yes_ No Neighbor Notification: (12) Required? Yes_ No_ Ifneeded,are agreements,easements, etc.properlyfiled? Yes _ No Section IV. (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 [ ] Approved/Granted—Subject to all comments,conditions and requirements noted in Sections 11 and M. Local Health Officer (13) Date: DOH 337-021 Page 26 of C RV HOLDINGTANKSITEPLAN: ❑ PROPERTY LINES&EASEMENTS ❑ EXISTING&PROPOSED STRUCTURES ❑ DRIVEWAYS&ACCESS ROADS ❑ EXISTING WATERLINES ❑ EXISTING&PROPOSED WELLS ❑ PROPOSED HOLDING TANK LOCATION ❑ SURFACE WATER SOURCES(LAKES,SALTWATER) ❑ APPROXIMATE RV LOCACTION ❑ CRITICAL AREAS(STEEP SLOPES,CREEKS,WETLANDS) ❑ NORTH ARROW&SCALE BAR REFERENCED SETBACKS PER WAC24&272A-0210: TANKTO SURFACE WATER AND/OR PRIVATE WELL-SOFT TANKTO BUILDING FOUNDATION-SFT TANKTO COMMUNITY WELL-1 OOFT TANKTO PROPERTY OR EASEMENT LINE-5FF TANKTO CRITICAL AREA-CONTACT PLANNING DEPT. TANKTO WATERUNES-TOFT 2209040MASON CO WA 0T Return To IIitili�I NMI 1111IllM',I 1111I�I mY�IN PO BOX 332 HO`ODSPORT WA. 98548 S wdYOh p'�\� Grantor(s): (1) SHARON DILL (2) Grantee(s): (1)PUBLIC Legal Description(1) Soo -T IA - fCLL (Abbreviated form:is. at black,Plat or section, township, range) Assessor's Tax Parcel: (1)49Q4—__- 51_- 00013 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 Q_day of��tc - ., 20]kq. (;gnatureoTGranior�: ( ) ��111 2 State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, aONotary Public in nd f r the above named County and State, do hereby certify t`haLt(on/this oc( y d of W, 20y� or�� 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 year last above written. Alf. Notary Public in and fo the State of Washington, M residing at ! My commission expires: : ,, 44P, El hr 3lO�: '' OPWABHN10N 1i Page 2 of 2