HomeMy WebLinkAboutwai2025-00028 - WAI Health Waiver - 4/18/2025 415 N.6`'STREET,SHELTON WA 98584
'"�� �'����:� SHELTON:360-427-9670,ext 400
'' rs, MASON COUNTY
BELFAIR:360-275-4467,ext.400
.' .i i. . ' COMMUNITY SERVICES ELMA:360-482-5269,ext.400
I-�r', ° ', FAX:360-427-7798
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Building.Planning,Environmental Health,Community Heald•
Application for Waiver or Appeal C
El
Amount Paid: Receipt Number ' 0ZO�g U E
APR 11 2025
WAI 202 - rrX1
B A
Instructions: �"""�
1. Complete Parts 1 and 2. No determination can be made until these parts are fully comoleted,
may2be billed for waivers and appeals, based on the Environmental Health Fee Schedule.
3 Fees
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant & Parcel Information Empire Home Construction (360) 751-8062
Name of Applicant
Telephone
Mailing Address PO Box 241 WA zi 98626
Kelso, State p
City 2 1 5 5 0 1 0 1 3
Parcel No. 3 __--2 0— — — — —WA 98584
Site Address
111 E Ashwood Ln, Shelton,
Shorecrest Terrace/ Div 2/ Blk 1/ Lot 1
3
Subdivision Na
me and Lot
4 PART 2: Nature of Waiver/Appeal
B
0 Food Sanitation Requirements
❑ Onsite: Class Waiver 0 Group B Water System Regulations
❑ Onsite: Class B Waiver 0 Water Adequacy Requirements
❑ Onsite: Class C Waiver 0 Building Permit: EH Review Policies
Et Onsite: Location, WAC246-272A-0210 ❑ Appeal: Enforcement Timelines
❑ Onsite: Holding Tank,WAC246 272A ❑ Appeal: Departmental Determinations
0240❑ Onsite: Contractor Certification ❑ Other
Requirements
Description of Waiver/Appeal (include justification, additional material may be attached.):
Reduce setback from back (east end) of house to drainfield
the e from
nd 10of the feet
down
house and to
w a
ll
minimum of 2 feet. Mitigation is that the drainfield is down-slope
drain away from the house. Also reduce setback from the left(north side)property line to the drainfield
from 5 feet to a minimum of 2 feet. Mitigation is that the drainfield is down-slope of the property line
and effluent will drain away from the property line.
Date: "l �� U
Applicant Signature: Dom— R,n i;ed K t 3/2ui S
�.- ''�- Web site.
This form may be scanned and available for public view on the Mason Coun
rage 1of2
PART 3: Public Health Evaluation (Staff Use Only)1. Type cable)
e of Determination Required: Type of Onsite Waiver (if applicable)
I,
Class A Class B Class C
Appeal ,Waiver None required
2. Identification of Specific Code/ Standard/ Determination (include date ofof determination or
latest Code! Standard revision):
3. Nature of Appeal:`nhoYi iinfa i {(, '
Ifi-
-k � p toSte-,
4. Hearing Official: 0 Health Officer
❑ Board of Health ❑ Public Health
❑ Pollution Control hearing Board 0 PEublic Heal h Directore Manage
❑ Certified Contractor Review Board
5. Mitigating Factors: (� J 1/ '1 -- .
_ + 0r eV ,t
6. I have received this waiver/appealreq request. It is complete and mitigation required by the
state and local policy has been sub
(1.01Y) Date:
Staff Signature: ``
El
PART 4: Determination of the Hearing Official
Ix The hearing official has determined that approval
of this request will not adverselyaffect 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: 4� y'f
Health Official Signature: Revised 8/13/2018
This form may be scanned and available for public view on the Mason County Web site.
Page 2of2
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