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HomeMy WebLinkAboutSWG Inactive OFFICIAL USE ONLY MASON COUNTY COMMUNITY SERVICES "° m �NnM�m�,m�xeelN�mvon,ne„MINUMI z w 5WG p - a 2 U1 ON-SITE SEWAGE TANK ONLY APPLICATION a a a n APPLICNR m RM)NE � Tara 8 Jay Jerrells (360) 507-3328 m c MNuxc AOCRE88-SREEEcm sTATE,IP CGOE CD 3 P.O. Box 1933, Shelton, WA 98584 n In 91iEMYflF99-3111fET.tIIY IPGCOF c - 70 N. Kings Way So., Hoodsport, WA 98548 V" Nu.1E aF OEsmxFn RKNE , Dale L. Tahja (360)4265940 NNIEOF NSTPLUR PIKt6 0 T. J. Goos (360)490.0217 z TVPEOF wowcr+.VMo..I CRFNFw WMERSOURCE // W NNEWCONSTRUCTION/UPGRADES 0PRNATE INDNMIALWEu 0PRNATETWOiMftRwei 2 courwErli@Iro SEREPIAC�IFMTA11E0 e PUBLIC WATERSYSTEA1 PUD Ni _ O SEPTK.TANK OPUMPTMIK ■RVNOLDNGTANK IMNOWB Lm� IN V a OTHER 0.19 acre a oTNFA CETALS rwArtaTFW KM9 TNlfR18E10KILC1ECl69T Q 0SURFACINGSEWAGE DEXBNNGFNLURE 13SN LINE M tOOFf+PU&.IfI COMMUNITY WELLS I^ SUBMITTALS N SOFF-PRNATE WELLS,SURFACE WATER%STREANIS.RIVERS ( M1J PLOT PLAN(REOUIRED) 0 TANK CROSS SEGTION(REOMRm) 14WT-DRMKINGMTERSUPPLYLNES IO E3 PUMP ITETNLS(IF APPLICABLE) 0WANER(S)IFAPPLICABLE) xT+PROPERTY/EASEMENT LINES.FOUNDATIONS,FOOTNGS RAT%AN CNECI¢leT Q p PRDPERTY LINESANO EASEMENTS N E%ISTNG/PROPOSEDGTRUCTURES E%ISTNGI PROPOSED OSS COMPONENTSAND LNES QWELLSWITHIN1WFr SWATERSUPPLYLNES MORIVEWAYSIPARKING OSURFACE WATERS,STREAMS,RVERS,ETG.. r — T � ONECTIONOFSLOPE/CONPOIIRS EIPERIM CURTNNDRNNS NORTH ARROW SCALE BAR GO P/^ OIIECTNNSTOBREIR08ffE CCMfIpNA ray.bobtlpve) Go north on Hwy 101 to Hoodsport, left on Lake Cushman Rd-, left on Cushman-Potlach Rd., left on Rainbow Way, right on Chinook Dr., left on Kings Way So., property on the right. ---------- OFFICIAL USE ONLY BELOWTHIS LINE - ----- UPGPADEIFNWRESWRCEPtt IgMl,q Pup ) OVOLUNTARY [3MAINTENANCE/PUMPING ❑WILDNGPERMIT j3HDF.ESALE r)COEPLA r]OT CAMMENTSICO DIIGNS I2 v HoYt'fi) Tont SSW TANKS MUSTBELISTEO UNDE0.IXN LSTOF NE0161ERFll 6EWIAETANNS'.TRY®NATIEETCMWFNFMNMW8NEIEWF®Bli3,ECYFEDMRI PMETS M0L0ST0SURFAMANOINQLCEMU9UUFNTMTER(F� fEC018l d1AWNRMU NeTIWAICN RFAORf1EgIF®FORFWLMRIOWL. INSPECTIX1610NATURE MTE AR'lIG1TbN EWIMTKM Wm MHKATIONN4ROVT3Y 189)EDBY MTE THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC AM ON THE MASON COUNTY WEBSITE REVISEOSTWK)I' cam, E\ 1 J 5100274 'Dais L.Tah' LICENSED DESIG R Holding Tank Sewage Systems-Paco®ended Standards and Guidance Effective Date:July l 2021 Introduction A Holding Tank Sewage System(HISS)is as alternative to a conventional ou-site sewage system with very special and limited applications. Simply,the HTSS provides a means to collect and temporarily store sewage from a facility or dwelling,for subsequent removal and transport to an approved treatment and disposal site. Depending upon the facility served or the particular set the use of a HTSS the expense of sewage pumping, hauling, and Lances surrounding P of circumstances g disposal at an approved facility can be very costly,especially on a long-term basis. In addition, the potential for operational/management problems with resulting public exposure to raw sewage is significant. For this reason,use of a HTSS must be closely regulated by the local health agency. A HTSS is an on-site sewage system that incorporates a holding tank,the services of a sewage pumper/hauler,and the off-site treatment and disposal of the sewage generated at the site served by the HTSS. Figure 1. LongittudiaalSection of Typical Holding Tank Sewage System. •a Warning Light and Audible Alarm Access Riser with secured pumping Access Port with gas tight lid g/sloped concrete pad Inlet from tu67 structure 1 tM.t Pipe Reserve Storage Volume Normal Operating Volume 14 "Septic tanks with plugged outlets are not allowed.Tank must not have an outlet. Rggym�► 1400y0 DOH 337-006 Page 6 of 17 SON CUUd yaF Public Health AWA Wmwig for a sahr that mie Knoncounty PO Box 1666,415 N 6s'Street,Bldg B,Shelton WA 9a584, Sheton:(360}427-9670 ext400 4 Wfair.(360127S-4467 ext 400 4 61ma:(360)482-S269 eA 400 FAX (360)427-7787 Application for Nyaiver/Appeal Atnouat Paid: WL Receipt Number: ZQZ -0070ry/ ' Instructions W fi T 707 q -NO 1 ti 1. Complete Parts 1 and 2.No determination can be made until these parts ane fully comma. 2. Fees may be billed far waivers and appeals,based on the Environmental Health Fee Schedule. 3. Submit completed application with atlechmmts to Mason County Public Health for review. PART 1.Applicant/Parcel Identification Name of Applicant Tara $ Jay JerrellS Telephone (360) 507-3328 Mailing Address of Applicant P. O. Box 1933 city Shelton 9 > State WA Zip 98584 q 12-digit Tax Parcel No. ate. 1 tO - - Q © y_ Site Address 70 N. 14ngs Way So., Hoodsport,WA 90548 Subdivision Name and Lot Lake Cushman Div. 12 Lot 88 PART 2:Nature of Waiver/Appeal ❑ Class BReducmatinVabW Separation ❑ Food Sanitation Requirements ❑ Building Permit Review Policies ❑ Cnoap H Water System Regulations ❑ J=ntkom,WAC 246-272A-0210 ❑ Water Adequacy Requirements 5( Holding Tank WAC 246.272A-0240 ❑ Enforcement Timelines ❑ Mason County Comte Standards ❑ Department Detennin coons ❑ Cm m car Certification Requirements ❑ Other (Installer,Pump 'O&M Specialists) Description of Waiver/Appeal(include justification,additional material may be attacbed.): Install Holding Tank for Recreational/Part-time Use(RV) Meets RSnGs for Holding Tank Deal n and is on state approved Ilst. Tracking of maintenance ttnmgh Meson County maintenance database, Carmody Inc. Applicant Signature: Cry Date: Revised 1L1L2014 This form may be scanned and available for public view on the Mason County Web sibs. Page 1 oil 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 ❑ 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 ❑ HeaMOgicer ❑ Pollution Control Haring Board ❑ Public Health l3trector ❑ Certified Contractor Review Board 0' 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 YC,2WJFOZ S.HIGH WATER AUDIOMSUAL ALARM, RISERS TO SURFACE,WATER-TIGHT FIRINGS 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:�_r//1/ Date: 310120ZLI. PART 4: Determination of the Hearing Offfdal ❑ The hearing official has determined that approval of this request will not adversely affect public health and is herebygroated.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: Date: y z Z Re fined 1?R2=4 Thia form may be scanned and awlMt"for While view on the Maaon Comity Web site. Page z oft Chanting waivers from Star O"ite Sewage System Regulations;Chapter 246-272A WAC Effective Dar: July 1,2007 Revised April 2017 On-Site Sewage Systems (Chapter 246-272A WAC) Request for Waiver from State Regulations Section[, (completed 6y appliant) Name: ()'Tara & Jay Jerrells focal Health Depmmtent/District (2) see inrbuctems Add"'& P. O. Box 1933 Shelton, WA 98584 Telepboae: ( ) 60) 507-3328 Signatum: Property tifiea on: (3) Tax Parcel#42216-52-00088 Lake Cushman Div. 12 Lot 88 Section II. (cmapleredby applicant) WACNumber. (4) WAC Require, (3) Waiver Sought (6) 246-272A— 0240(2) holding tank used for pernamard Mnot*used for part4lrne recreational use Subsection: commercial uses r Justification(mitigation measures m be provided): (7) aea 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 1111. (completed by health officer) Review Criteria: (8) Mitigation Measures(m addition to those proposed): (4) Comments/Conditions: (7a) Type of Waiver: (11) W Class A [ ]Class E [ ]Class C—Request DOH review before granting! Ya_ No Y Neighbor Notification: (12) Required? Yes_ No_ Ifneeded,are agreements,easements.elk.properlyfrled? Yea — No Section IV.. (completed by health officer)This Request For Waiver From Star Regulations has been reviewed according to the provisions of Chapter 246-272A WAC On-Sir Sewage Systems. The review criteria applied,and the mitigation measures proposed and/or mquurd,have been evaluated for the¢ability m provide public health protection at least equal to that provided by this chapter WAC. Denied [ ]Approved/Granted—Subject to as comments,conditions and tequirmnenre noted in Sections 0 and Ill. Health Officer (13) Date: z4 - DOH 337-021 Page 26 of 32 Mason County Community Services 415 N. 61h St. Shelton,WA 98584 January 27, 2024 Subject: Operational Agreement Parcel#: 42216-52-00088 Address: 70 N.Kings Way S.,Hoodsport,WA 98548 The intended use of the Septic Holding Tank located at the above referenced property is for recreational use.The use is low flow, and the pumping service frequency will be"On Call". The system will be routinely monitored and pumped by a Certified Mason County Septic Pumper when needed.At a minimum,the holding tank will be pumped once annually and inspected to ensure proper functioning. Respectfully, iay &Tara JerrelIs (property owner) 2207902 MASON CO WA 0Rgg6JEFRELLS Ris52s6 Rec Fe - VO4 60 Geees. 2 Rat"TO �n� a lull III owl IgglIj P.Q. I&A N33 M sIc4,7241 WA -IS 5gy �W FEB Z B 1024 TT RSIC VFD Grantor(s): (1) In>zA tTERRE4,S (2) JAY JiFRRL245 Grentee(s): (1)PUBLIC Legal Description(1) RUG ''I TwA 22 ScG, 16 (Abbreviated form:As.lot,Mock.plat or section.fownd* range) Assessor's Tax Parcel: (1) '1 2 ? l 6 - 5 Z - 0 0 0 q 8 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 malgation 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 �(" day of ilt f lL(4I1- 202�L Signature Qd Grantor(s): 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 certify that on this-a-4—day of Q UILAr.xu 20RLJ , lfA t\ )AV 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. L ��' � �� blic in and for the State bt Washington, a 1.PFF�y,g.2d7'�w ,ys� residingat AAt4 )N C(A,tvtEW Mycommission expires: 0S-t5 d-1 tS PUaI\G �i?_ Page 2 of 2