HomeMy WebLinkAboutWAI2025-00049 - WAI Health Waiver - 6/25/2025 MASON COUNTY
Public Health & Human Services
PO Box 1666,415 N 6th Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 ❖ Belfair:(360)275-4467 ext 400 :• Elma:(360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid:
Receipt Number:
Instructions W (� a-oas- 0 op 1-kci
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
Jacob Nolte Telephone (503) 593-7914
Mailing Address of Applicant 14709 26th Ave NE
City. Shoreline, State WA Zip 98155
12-digit Tax Parcel No. 2 2 0 2 1 __ 5 0 __ 0 0 9 0 0
Site Address 1141 E Benson Loop Rd, Shelton, WA 98584
Subdivision Name and Lot Concord Beach Addition, TR 1 S of R/W &T.L.
PART 2: Nature of Waiver/Appeal
❑ Class B Reduction in Vertical Separation 0 Food Sanitation Requirements
❑ Building Permit Review Policies 0 Group B Water System Regulations
❑ Location.W AC 246-272A-0210 0 Water Adequacy Requirements
1.9' Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
❑ Contractor Certification Requirements 0 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: 44ACQk1071 -1Date: 6-
` t t- . ' Revised 12/12/2014
This form may be scanned and available for public view on the Mason County Web site. Page I oe2
PART 3: Public Health Evaluation (Staff Use Only)
I. Type of Determination Required: Type of Onsite Waiver(if applicable)
Appeal Waiver None required KiClass 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 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board
®' 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 5/i blj_______
4. NOTIFICATION TO FUTURE OWNERS RECORDED ON PROPERTY/PARCEL OPZZZ p
, 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: /(ei'3 ? f
PART 4: Determination of the Hearing Official
4. 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:
Date: / l°/f
Revised 12/12/2014
This form may be scanned and available for public view on the Mason County Web site. Page 2 or 2
ff Granting Waivers from State On-Site Sewage System Regulations Chapter 246-272A WAC Effective Date: July 1.22007 Revised April 2017 I 1111 On-Site Sewage Systems (Chapter 246-272A WAC)
Request for Waiver from State Regulations
Section I. I (completed by applicant)
Local Health Department i District (2)
Name: (1) Jacob Nolte (see instructions)
Address: 14709 26th Ave NE alq5Cti GA `/
Shoreline, WA 98155
Telephone: ( ) (503) 593-7914
Signature:
Property Identification: (3) Concord Beach Addition, TR 1 of RNV&T.L. —SEC21, TWP2ON, R2W
Site Address: 1141 E Benson Loop Rd, Shelton,WA 98584
Section II. I (completed by applicant)
WAC Number: (4) WAC Requirement: (S) MWaiver Sought: (6)
246-372A— 0240(2) holding tank used for pernament holding tank used for part-time recreationaluse
.. . ____....__...._...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. I (completed by health officer)
Review Criteria: (8) Mitigation Measures(in addition to those proposed): (9)
Comments/Conditions: (10) 5e& fr1..._... w4€ver WWa(15W i _ . _.._-_
............
• (Aaftz 10 f'v>fvf o� of fecrea ....1.. d v..._howl.
4�rc/ re co h ArV: zz2?Y3 7
Type of Waiver: (11) l Class A [ ]Class B ( ] lass C—Request DOH review before granting? Yes No x
Neighbor Notification: (12) Required? Yes_ No X 1f 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.
1 ] Denied [ ] Approved/Granted—Subject to all comments.conditions and requirements noted in Sections II and Ill.
Local Health Officer (13) Date:
Page 26 of 32
DOH 337-021
Jacob Nolte
14709 26th Ave NE
Shoreline, WA 98155
May 28, 2025
Mason County Department of Health Services
415 N 6th St
Shelton, WA 98584
RE: Jacob Nolte RV Holding Tank, Parcel#22021-50-00900
Dear Inspector:
As part of the application process for installation of an RV Septic Holding Tank located at 1141 E Benson
Loop, Shelton, WA 98584 we agree to have the tank pumped on a regular basis with a minimum of
annually. The tank will have a high-level alarm and we will engage a local septic pumping company to be
on standby for regular pump-outs.
If you have any questions, please feel free to get in touch at jacobcnolte(a gmail.com or by my phone
number listed below.
Sincerely,
a Nolte (._
03) 593- 14
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