HomeMy WebLinkAboutWAI2023-00008 - WAI Health Waiver - 1/31/2023 r
415 N.6'''STREET,SHELTON WA 98584
/ ; , ._\, MASON COUNTY
SHELTON:360-427-9670,ext 400
COMMUNITY SERVICES BELFAIR: 360-275-4467,ext.400
ELMA:360-482-5269,ext.400
Building.Planning,Environmental Health,Community Health FAX:360-427-7798
;,nplic:• n for Waiver or Appeal
Amount Paid: }' '•.,. `' Receipt Number: l �� I ,
WAI �� )—)7 6b06 JAN 3 1 2023
Instructions: &
1. Complete Parts 1 and 2. No determination can be made until these parts are fully coYnptete
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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 Information
Reginald & Michelle Tweed Telephone (701 ) 333-8574
Name of Applicant g
Mailing Address P.O. Box 371
City Carlsborg, State WA Zip 98324
Parcel No. 3 2 0 0 3 -- 4 2 -- 0 0 0 1 1
Site Address 4000 E State Route 3, Shelton, WA 98584
Subdivision Name and LotTR 1-A of GOVT LOT 3 SURVEY 6/113 & 8/55
PART 2: Nature of Waiver/Appeal
❑ Onsite: Class A Waiver 0 Food Sanitation Requirements
❑ Onsite: Class B Waiver 0 Group B Water System Regulations
❑ Onsite: Class C Waiver 0 Water Adequacy Requirements
35-51' Onsite: Location, WAC246-272A-0210 0 Building Permit: EH Review Policies
❑ Onsite: Holding Tank,WAC246-272A- 0 Appeal: Enforcement Timelines
0240 0 Appeal: Departmental Determinations
❑ Onsite: Contractor Certification 0 Other
Requirements
Description of Waiver/Appeal (include justification. additional material may be attached.):
Reduced setback from Owner's private well to septic drainfield from 100 ft down to
75 ft. Land is generally flat with little slope. Minimal slope is not toward the well. The onsite septic
system using a NuWater BNR-500 meets Treatment Level B without disinfection and pressure distribution.
The system has a timer, elapse meter and event counter to ensure the drainfield is not being overused.
This site also has excess vertical separation at 30"+ (to be held at 24" minimum).
Date: 1-30-23
Applicant Signature:--� ,, �
Ov -e__$e. ' `L' �C' -c Cll -- Revised 8/13/2018
This form may be scanned and available for public view on the Mason County Web site. Page 1 oft
PART 3: Public Health Evaluation (Staff Use Only) IOC °Vt
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): — dxt Co
3. Nature of Appeal: / f c ct+,o./ 4---a -,... e i l 7 S
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board ❑ Environmental Health Manage
5. Mitigating Factors: j L --6 N C D. 3' �/d,J
well a p5IoP /s l St A � e
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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:
(/>/1 Date: 2-/Y- 2
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:
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:
Health Official Signature:
tr\-1 Date: 2107/1 j
Rcviscd 8/13/2018
This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2