HomeMy WebLinkAboutWAI2023-00091 - WAI Health Waiver - 8/24/2023 415 N. 6'^STREET,SHELTON WA 98584
( , MASON COUNTY SHELTON. 360-427-9670,ext 400
COMMUNITY SERVICES BELEAIR.360-275.4467, ext 400
ELMA. 360-482-5269,ext.400
Budding.n=wins Env.ronmentai Heaim.Conn ,ty enue FAX:360-427-7798
. . . for Waiver or Appeal
Amount Paid. t " .. Receipt Number p
WAI .i.a Z3 Q a CA
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 8 Parcel Information
Name of ApplicantEmpire Home Construction Telephone (360) 751-8062
Mailing Address PO Box 241
City Kelso, State WA Zip 98626
Parcel No 2 2 0 1 7 5 0 0 0 0 4 5
Site Address 560 E Lakeshore Dr E, Shelton, WA 98584
Subdivision Name and Lot Timberlake, Div 2, Lot 45
PART 2: Nature of WaiverlAppeal
❑ Onsite: Class A Waiver ❑ Food Sanitation Requirements
❑ Onsite: Class B Waiver 0 Group B Water System Regulations
❑ Onsite: Class C Waiver 0 Water Adequacy Requirements
Onsite. Location, WAC246-272A-0210 0 Building Permit EH Review Policies
❑ Onsite: Holding Tank, WAC246-272A- ❑ Appeal. Enforcement Timelines
0240 ❑ Appeal:Departmental Determinations
❑ Onsite: Contractor Certification 0 Other
Requirements
Description of Waiver/Appeal (include justification. additional material may be attached.).
Reduce horizontal separation between house foundation and drainfield from 10' to a minimum of 2'.
Mitigation: Land slopes away from foundation. Drainfield effluent will drain away from foundation, not toward it.
Applicant Signature. � Date: - 2-4-2.3
C1vc>,St b flail able bZ licvi view
the Mason
v 'i. 8'132618
This form may be scion a d available for p lic view on the Maso County Web site.
ry s_ior2
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver (if applicable) /.�-�
: Appeal 7Naiver None required Class A Class B Class C c 1
2. Identification of Specific Code/Standard/ Determination q(include date gf deteymination or
W I
latest Code/ Standard revision): rv" i i Z. r LA- CIZ'LD
3. Nature of AppealV-044 I9A lVJct C� � ff`iv"1
-Q k ' `
4i� xeN dLarri- .'^ tp d yu f, "SA
Wmt ttuUM' c 4 2 kh
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board Y� Environmental Health Manage
5. Mitigating Factors. cludAy,Arcr. L � Cj.,t{.,yC{—
�10 �etr1�EX 4�^
YI^2sItert t-t«* ofM tin S
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: it d. Date. tb/" (2-3
PART 4: Determination of the Hearing Official
cg 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:
,('(.�„/ Date: ('7`44.1
Health Official Signature: 7
Rc ised&URUI8
This form may be scanned and available for public view on the Mason County Web site. 2