HomeMy WebLinkAboutWAI2025-00004 - WAI Health Waiver - 1/23/2025 MASON COUNTY
COMMUNITY SERVICES
Building Planning Environmental Health,Community Health
415 N 6"Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 - BelfF� 0) 42
36 2 �87 M 400 4 Elma: (360)482-5269 eext 400
Application for Waiver/Appeal IM
Amount Paid: zooReceiptNumber: p0' 00N00
Instructions b)A12025 - occ)04I
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 THOMAS v 88 Telephone
Mailing Address of Applicant PO BOX W9
City TAHUYA State WA Zip 98888
12-digit Tax Parcel No. 3 2 a 2_7 =— 2 2 =_0
Site Address 14891 NE NORTH SHORE RD
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
❑ Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation ❑ Food Sanitation Requirements
JBuilding Permit Review Policies ❑ Group B Water System Regulations
`W Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Orate Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification,additional material may be attached.):
REDUCE SETBACK FROM FOUNDATION TO DRAINFIELD, 1OFT DOWN TO 2FT+
FOUNDATION IS UPGRADIENT
Applies M Signature: L a Date:
1 21 ZS'
f;c9arF f�,fss.G
1dEH Farms\Waiver-Appeal Mason County Local Revised I I20120❑
Page I oft
PART 3: Public Health Evaluation (Staff Use OWY)
1. Type of Determination Required: Type of Onslte Waiver(If applicable)
❑Appeal rNaiver ❑ None required ❑Class A ❑Class B ❑ Class C
2. Identification of Specific Codel Standard/Determination(include date of determination or latest Code/
Standard revision)
3. Nature of Appe AA&CLY
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4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board ❑ Public Health Director
❑ Certified Contractor Review Board Environmental Health Manager
5. Mitigating Factors: 11
py-Al\.f't-el A I S yLrg�'��—
6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
Stall Signature: Date:
PART 4: Determination of the Hearing Official
yw-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: V, 6 Zf
JdEH Forms\Waive,Appcal Mason County Laval Revised 1/20/2017
Page 2 of
I
PUMP OUT&ABANDON ALL I NORTH SHORE RD 0
EXISTING COMPONENTS. I EXISTING
=MAINTAIN 10'+ FROM EXISTING WELL
WATERLINES TO NEW 055 I Q
COMPONENTS //�\ SHOP/GARAGE
/ - (W/NO FOUNDATION) �
EXISTING 055 �� \
PUMP OUT `
&ABANDON o
� O
REMOVE
SPRUCE TREE
1
DBL5LEEVE \
NEW 2"SCH. 40
TRN5PT. LINE PROPOSED /
(10'.EA.DIRECTION)_ -- DKAINFIELD /
- NEW
SHED TANKS
I
I 1� APPROXIMATE EXISTING
ABANDON 1 + 1 WATERLINE LOCATION
ry /
EXIST. T/LINE /
(
EXISTING
PUMP BASIN 1 I
PVMPOUT& EXISTING I
ABANDON HOME /
I
SHORELINE/
r 1
1I BULKHEAD /
1 i
I HOOD CANAL / `_, E PIRES.
AN ASSOILTI INSTALL SMNOFF FEE WILL
RE CHARGED AT THE W INSTALLAMN
CUSTOMER THOMAS W EBB TEST HOD[ TEST HOLE 2
PIONEER DIGGING, INC. PAKCELk32227-22-00140 a s�S' e31� 1ONP
SEPTIC DESIGNS ADDRESS 14891 NORTH SHORE RD ROOTS @ 35 ROOTS@ 31
3U83 E M950N GFNSON aD. cMPEVIEW,w.49dsss DFSIGNEA: AOBERT H.PAYSSE
OFWF- tM2618C3 FSS-3Rt 27-2353 SHEET. SITE PLAN SCALE 1'=30' E.,.a.°'•"°'•"'�"`•"'•""�"""°°""