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Home My WebLink AboutWAI2025-00017 - WAI Health Waiver - 3/18/2025 MASON COUNTY Public Health & Human Services PO Box 1666,415 N 6th Street, Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 0 Belfair:(360)275-4467 ext 400 0 Elma:(360)482-5269 ext 400 FAX (360)427-7787 Application for aiverr ppeal Amount Paid: �� Receipt Number: �7/0�K— 61 4 7,,7 ^ /s Instructions I. Complete Parts 1 and 2.No determination can be made until these parts are fully completed. 2. Fees maybe 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.Applicaut/Parml Identification Name of Applicant TERESA BARTLETT Telephone 415-656-7999 Mailing Address of Applicant 605 HILLCREST AVE City KENT State WA Zip 98030 12-digit Tax Parcel No. 3 2 3 0 9 __ 5 0 _ 0 1 0 1 5 Site Address 191 N PARADISE DR, LILLIWAUP Subdivision Name Bud Lot COLONY SURF 1, Lot 15, Block 1 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 ❑ Water Adequacy Requirements d Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines ❑ Mason County Onsite Standards ❑ Departmental Determinations ❑ Contractor Certification Requirements ❑ Other (Installer,Pumper,O&M Specialises) Description of Waiver/Appeal(include justification,additional material may be attached.): Install Holding Tank for Recreationall 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:.al.A � Revised 12/122014 This form may be scanned and available for public view on the Mason County Web site. Page 1 of 2 PART 3: Public Health Evaluation(Staff Use Only) 1. Type of Determination Required: Type of Onsite Waiver(if applicable) ❑ Appeal VWaiver O 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 E� 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 AUDIOMSUAL 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: � �I`��S 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: Hearing Official Signature: Date: Revised 17/17/2014 This form maybe manned and available for public view on the Mason County Web site. Page 2 of 2 (,UQ.c.aQ�S MOl? 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 )VAC) Re nest for Waiver from State Regulations Section 1. (completed 3 ,Fplicam) Name: (p TERESA BARTLETT Local Health Department/District (2) ............. .._- see instructions) Address: 605 HILLCREST AVE KENT, WA. 98030 Telephone: ( ) 415-656-7999 _ — --�-� """ _ _2_ —. Signature --_ .__- Property Identification: (3) Site Address:191 N PARADISE DR, LILLIWAUP Legal:COLONY SURF 1, Lot 15, Block 1 Parcel#323095001015 Section IL (completed byapplicam) WACNumbm (4) WAC Require mem: (3) Waiver Sought (6) 246-272A— 0240(2) holding tank used for pemament holding tank used for part-time recreational inas 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 officer) Review Criteria: (6) Mitigation Measures(in addition to(hose proposed): (9) Comments/Conditions: (10) Type of Waiver: (11) ]-Class A [ ]Class B [ ]Class C—Request DOH review before granting? Yes No Neighbor Notification: (/2) Required? Yes_ No Jfneeded are agreements, casements, etc.properlyfiled? Yes No Section IV. (conipleied by health grker) 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 healthprotection at least equal tothat provided by this chapter WAC. [ ] Denied [Dq Approved/G led—Subject to all comments,conditions and requumcmerP not in Sections If and Ill. Local Health Officer (13) Date: l;r 2_ DOH 337-021 Page 26 of 32 Mason County Community Services Environmental Health 415 N. 61h Street Shelton,WA 98584 1 Teresa Bartlett would like to install a Recreational Holding Tank located at: 191 N PARADISE DR, LILLIWAUR I Agree to have the sewage tank pumped by a licensed Mason County Septic Pumper as needed, minimum once annually. Sign: Date: Li r, TERESA BARTLETT 605 HILLCREST AVE Kent, Wa. 98030