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Home My WebLink AboutWAI2025-00020 waiver # incorrect on paper - WAI Health Waiver - 4/23/2025 r 415 N.6°'STREET.SHELTON WA 98594 SHELTON:360-427-9670,ext 400 MASON COUNTYBELFAIR:360-275-W7,ed 400 COMMUNITY SE ACES ELMA:360492-5269,ext.400 FAX:360-427-7799 euJ4�,4pymig Em++n^TenU�MeiM.Canmuniry MmNh } �FA\DnDlication for Waiver or ADppeal p 11N� ( `"f(o Amount Paid: '� Receipt Number : ''1IIISS�. 2025 00025 WAI ------'__ Instructions: 1. Complete Parts't and 2. No determination can be made unfit theca Parts are fully completed. application with attachments to Mason County Public Health for rem.aW. 1 fees may be billed for waivers and appeals, based on the Environmental Health Fee Schedule 3. Submit completed PART 1. Applicant& Parcel Information Scott Gordon Telephone 360-731-2233 Name of Applicant Mailing Address 91 E Twanoh Falls Dr 98528 city Belfair, safe WA Zip--I 3 2 0 0 2 6 Parcel No. — — — — — Tahu a WA 98588 Site Address 620 NE Dewatto Rd, Y Site Addresision Name and Lot Tee Lake Shore Acres TR 26 S 511159 PART 2: Nature Of WaiverlAppeal ❑ Food Sanitation Requirements ❑ Onsite.Class A Waiver ❑ Group B Water System Regulations ❑ Onsite:Class B Waiver ❑ Water Adequacy Requirements ❑ Onslte: Class C Waiver ❑ Building Permit. EH Review Policies 0 Onsite:Location,WAC246-272A-0210 [I Appeal Enforcement Timelines ❑ Onsite:Holding Tank,WAC246-272A- ❑ Appeal:Departmanral Determinations 0240 ❑ Other ❑ Onsite: Contractor Certification Requirements Descdption of Waiver/Appeal(include justification, additional material may be attached.)'. .Setback from owner's well to owner's drainfield be reduced from 100 feet to a minimum of 75 feet. Midgation is that the dreinfield is down-slope of the well. Owners well lag aaEdted ahowhng 0-40 n wi ayer. Date: 4-23 2—_-5--- Applicant Signature. 6"xtl^ Bcvlwc4 xn)llalx I�d available for pub vrew on the Mason County web site. Yegs I nf2 This form may be scann PART 3: Public Health Evaluation (Staff Use Onl» Type of Onsite Waiver(if applicable) I. Type of Determination Required: Class A Class B c Class C L ' ❑ Appeal )`Qalvef None required -- 2. Identification ofSpecific Code/Standard/Deter�ninatioDl(incl de at�Ue?r(rr�'Ination or w latest Code/Standard revision): y 3. Nature of Appeal: u - 4. Hearing Official: ❑ Health Officer ❑ Board of Health ❑ Public Health Director ❑ Pollution Control hearing Board pt, Environmental Health Managef El certified contractor Review Board T 6. Mitigating Factors: I 0-F h�a� v 6. 1 have received this waiver/appeal request. It is complete and mitigation required by the state and local policy has been submitted. Date: Staff Signature: ' 9- �I2 PART 4: Determination of the Hearing Official 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: L 1 Health Official Signature: R�0 siu2as This form maybe scanned and available for public view on the Mason County Web site• Page 2 of2 RECEIVED Mg 2 3 202§ WA state pePairkM"yYt IIYYARTM4NT 9i' NNitt o(Mmnl No.�E5200 {F 1ta[IfF�I>f/t WATER WELL REPORT . ECOLOGY uniRue&vvgYMrdIIDTrkNa.WQll1 iyFkiNYeM smrr ntwn.fiingten SIU\Y<ll Namc(if moreiWaoadrRil0: ----- �:CppYefbn ' 1 blWkn NOI W. �_ Wain Right PennitR:xfRdxa Nd.,_ .—_�•----- ❑�OweU:pifdo}.c? 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IJxs �Ne SMRMI?�t25t2k comkw Dkb: T<agaeaanafwxer__° lkRdwa, 11 V-akhalSma Wdl WELLL'ONSTADCTION CERTIFICATION: 1 denxructed nld/or uoept ugreuibililY loamliaUlran dim.well,eM iUcwaP doekhCSTRU e.Matalak Rrd0w hr(omWien fepwtd ebeve erd Y�emmY M51Wow1dge end belie[ . . pillml Cwapn Dads Down p pri0ec❑Taeiva❑PE-Print NnmeE DevIB Addrc 340 NE Davis FamRd .— SLwwN GIY.cam,7'e BellsD.WA 98526 TTRARHlMEC:3l2 Cwtwclm,a 1FT LiceaaeNa. Re ietaai- o-DAVISDI7100A DMVAY2024 S joj-eSipjshac CCY 0541-2DlRer OWl9)IJlop iuxYt µyflarpmeariaaa Mwrrmrcfdr.mr,PJen+r m//lbe IYumr Reroerrr+4774 -6341- Prwtiv wirAArerirM,Luf caw+nR]YJJnr IYaMrrkfoa"s,&rcke. Pnnu.a)rh arprrAJknbilYy can<mFBJJ-8d]-63t1.