HomeMy WebLinkAboutWAI2023-00006 - WAI Health Waiver - 1/23/2023M
'->'•~ :\ 415 N.6'STREET,SHELTON WA 98584
r'` MASON COUNTY SHELTON:360-427-9670,ext 400
BELFAIR:360 275 4467,ext.400
i-
.11. COMMUNITY SERVICES
: ELMA:360-482-5269,ext.400
\-, , - \,r,' Building,Planning,Environmental Health.Community Health FAX:360 427 7798
ADoll�ication for Waiver or Appeal
Amount Paid: -ti' '"l 0 Receipt Number: -1.-3 — 0 04
1 �0
WAI 2023 - 6000(0
Instructions:
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 Information
Name of Applicant
Sharron Koidahl Telephone (360) 253-1946
Mailing Address 450 E Penzance Rd
City Shelton, State WA Zip 98584
Parcel No. 3 2 1 2 7 -- 5 0 -- 0 0 1 1 0
Site Address 720 E Ballantrae Dr, Shelton, WA 98584
Lake Limerick/ Div 1/ Lot 110 s
Subdivision Name and Lot 1 JAN 2 3 Z023
PART 2: Nature of Waiver/Appeal i�
By
❑ Onsite: Class A Waiver 0 Food Sanitation Requlrements
❑ Onsite: Class B Waiver 0 Group B Water System Regulations
❑ Onsite: Class C Waiver 0 Water Adequacy Requirements
18' 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.):
Reduce horizontal separation between South property line and drainfield from 5'to a minimum of 2'.
Mitigation Measures: Land slopes away from property line. Drainfield effluent will drain away from
South property line, not toward it.
Applicant Signature:
Date: 1-20-23
V YL t 3c2_ ,;e4- -c-- Saz - -c— 0 L r— Re,i;ed s I;201 s
This form may be scanned and available or public view on the Mason County Web site. r.t_e I of
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable)
Appeal 1/Vaiver None required Class A Class B Class C LO C
2. Identification of Specific Code/ Standard/ Determination (include date of determination or
latest Code/ Standard revision): "-OZ(
3. Nature of Appeal: INA,1
[ - c ,lam tW f r to Z- --
4. Hearing Official:
❑ Board of Health 0 Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
O Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors: c d -- \02-
4Q -2 n0
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: ‘Rjr11\QJW\10({VV.\ Date: --/47 /-7--
PART 4: Determination of the Hearing Official
i�.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:
Health Official Signature:
Date: 2 77//
This form may be scanned and available for public view on the Mason County Web site. Page of 2