HomeMy WebLinkAboutWAI2024-00075 - WAI Health Waiver - 7/25/2024 MASON COUNTY
COMMUNITY SERVICES
Building Planning Env'nonmentnl Health Community Health
415 N 61"Street, Bldg 8, Shelton WA 98584.
Shelton: (360)427-9670 ext 400 6 Belfair (360)276-4467 ext 400 O Elms: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waivve�r/Appeal
Amount Paid:
Receipt Numbef:
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 Masan County Public Health for review.
PART 1. Applicant(Parcel Identification
Name of Applicant Jason Campbell Telephone 253-241-3594
Mailing Address of Applicant 11211133rd ST E
City Puyallup State WA Zip 98374
12digft Tex Parcel No. 3 2 3 Q 9 — 5 1 - 1 0 0 0 1
S8e Address 210 N Lake Surf OR Lilliwaup WA
Subdivision Name and Lot COLONY SURF 2 BLK: 10 LOT: t
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
® Separation ❑ Food Sanitation Requirements
❑ Building Permit Review Policies Cl Group B Water System Regulations
❑ Location,WAG 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
* Mason County Onsfte Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
Applying fora waiver to reduce set back to drainfield from 10'to 5'due to the nv w lot and the new home, the side
witatek would not be obtainable Based on elevations the drainfield aplaawn 0 be down gade from the hente
The Insoc is a rannufadomd home was,
�on a native soiV�vel foundation.No concrete is
Applicant Sign/turs. gIDifiatie:: 7/22/2024
1:\EH Forms\Waiver-Appeal Mason V County focal O iG t10 LS La 1/202017
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By
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
o Appeal aiver o None required o Class A ❑ Clasa B o Clase C LA;'(-z
2. Idemffication of Specific Code/Standard/Determination(include date of determination or latest Code/
Standard revision) w ?�
-72-lT^ -0�/l �
3. Nature of Appea �-
hwi ,2r-w�n, Sew rcrE 'fro �
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board / \
I Environmental Health Manager
5. Mitigating Factors: fA-,Y -41 , ( (S cU �
L
6. 1 have received this waiver/appeal request. It is w plate and mitigation required by the state and
local policy has been submitted.
Staff Signature: \V�" r ` Date: I ly
PART 4: Determination of the Hearing Official
C� 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: �-
1:\En Forms\Waiver-Appeal Mason County Local Revised 1202017
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