HomeMy WebLinkAboutWAI2024-00037 - WAI Health Waiver - 4/16/2024 MASON COUNTY 3 APR 23 2024 D
COMMUNITY SERVICES,
Buildin%Planning EmiranmeM l HaItK Community Health
415 N e Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4 Belfair: (360)2754467 ext 400 G Elma: (360)482-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid:
Receipt Number: Z
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 Identification
Name of Applicant NATHAN SHAFFER Telephone
Mailing Address of Applicant 15950 S LORA CT
City OREGON CITY State OR Zip 97045
12-digit Tax Parcel No. 3 2 1 2_7=_ 5 1 _ 0_0 2 7 2
Site Address 570 ST.ANDREWS DRIVE,SHELTON
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
❑ Building Permit Review Policies ❑ Group B Water System Regulations
V Location,WAC 246-272A-0210 ❑ Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 ❑ Enforcement Timelines
❑ Mason County Onsite Standards ❑ Departmental Determinations
❑ Other
Description of Waiver/Appeal(include justification, additional material may be attached.):
CLASS A WAIVER TO REDUCE SETBACK FROM DRAINFIELD TO DOWNSLOPE FOUNDATION DRAIN.
25FT DOWN TO 15FT+
MEETS CLASS A WAIVER REQUIREMENTS.TLB W/DISINFECTION a W OF VERTICAL SEPARATION 8 ANNUAL O/M.
Applicant Signature. Date: �
1:\EH Forms\Waiver-Appcal Mason County Local Revised 1/20/2017
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